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THERAPEUTICS  OF  THE   CIRCULATION 

BRUNTON 


THERAPEUTICS  OF 
THE  CIRCULATION 

EIGHT  LECTURES  DELIVERED  IN  THE  SPRING 
OF  1905  IN  THE  PHYSIOLOGICAL  LABORA- 
TORY OF  THE  UNIVERSITY  OF  LONDON  Jk 


BY 

LAUDER   BRUNTON 

KT.,  M.D.,  D.Sc.,  LL.D.  (EoiN.),  LL.D.  (ABERD.),  F.R.C.P.,  F.R.S. 

CONSULTING   PHYSICIAN  TO   ST.  BARTHOLOMEW'S   HOSPITAL 


PUBLISHED    UNDER    THE    AUSPICES    OF 
THE    UNIVERSITY    OF    LONDON 


TiUitb  240  Illustrations 


PHILADELPHIA 
P.    BLAKISTON'S   SON   &   CO 

IOI2    WALNUT    STREET 


PRESS  OF 

THE  NEW  ERA  PRINTING  COMPANY 
LANCASTER.  PA 


TO 
HUGO   KRONECKER 

M.D.,  D.Sc.  (CANT.),  LL.D.  (ABERD.  AND  GLASG.) 
ETC.,  ETC. 

PROFESSOR  OF  PHYSIOLOGY  IN  BERNE  AND  DIRECTOR  OF  THE 
MAREY  INSTITUTE  IN  PARIS 

THE   AUTHOR   DEDICATES   THIS   BOOK 

IN  ACKNOWLEDGMENT  OF  THE  GREAT   SERVICES   HE   HAS   RENDERED  TO   PHYSIOL- 
OGY, AND  ESPECIALLY  THE  PHYSIOLOGY  OF  THE  CIRCULATION/  IN    MEMORY 
OF    MANY    PLEASANT    HOURS    SPENT    TOGETHER    WHEN    WORKING    IN 
LEIPZIG     UNDER     THE     DIRECTION     OF     THEIR     BELOVED     MASTER 
CARL  LUDWIG,  IN   1869-70,  AND  IN  TOKEN  OF  A  FRIENDSHIP 
THAT    HAS    LASTED    EVER    SINCE. 


PREFACE 

THIS  book  consists  of  eight  lectures  which  were  delivered  in 
January,  February,  and  March,  1905,  in  the  Physiological  Lab- 
oratory of  the  University  of  London,  in  accordance  with  the 
general  purpose  expressed  by  the  University  in  the  establish- 
ment of  the  Physiological  Laboratory,  viz.,  "  to  present  the 
results  of  recent  investigations  by  the  investigators  themselves, 
orally  and  with  experimental  demonstration  in  the  lecture- 
room,  and  outside  the  lecture-room  by  monographs  approved 
by  the  University." 

By  the  kindness  of  Professor  Waller  and  of  his  assistant, 
Mr.  Syme,  the  lectures  were  illustrated  by  experiments,  which 
increased  their  value  to  the  students.  At  the  same  time,  the 
necessity  of  adapting  the  lectures  to  the  experiments  rather 
interfered  with  their  orderly  sequence,  and  in  consequence  of 
this  they  are  not  so  sharply  divided  into  the  various  sections 
on  Physiology,  Pathology,  Pharmacology,  and  Treatment,  as 
they  were  at  first  intended  to  be.  Semeiology  is  hardly  touched 
upon,  as  it  is  so  fully  discussed  in  lectures  on  Medicine,  and 
the  other  subjects  were  more  than  sufficient  to  fill  a  course  of 
eight  lectures. 

Opinions  may  differ  as  to  the  proper  selection  of  subjects 
for  the  lectures,  and  my  selection  may  be  disapproved  of  by 
some,  who  may  consider  that  I  have  spent  too  much  time  over 
such  subjects  as  "  Self-massage  of  the  Heart  and  Vessels," 
"  The  Conduction  of  Stimuli  in  the  Heart,"  etc.  My  reason 
for  doing  so,  is  that  I  consider  the  subjects,  on  which  I  have 
dealt  rather  fully,  to  be  of  practical  importance,  and  they  are 
dealt  with  shortly,  if  at  all,  in  ordinary  text-books.  I  had  also 
made  an  experimental  study  of  some  of  them  myself,  and 
in  accordance  with  the  general  purposes  of  the  University  in 


Vlll  THERAPEUTICS    OF    THE    CIRCULATION 

establishing  such  lectures,  I  presented  the  results  of  my  own 
investigations  more  fully  than  in  a  text-book.  The  lectures 
were  not  written  out,  but  were  delivered  from  short  notes,  so  as 
to  suit  the  experiments.  They  were  taken  down  in  shorthand 
by  Mr.  M.  A.  Donaldson,  and  I  have  to  thank  him  for  the 
remarkable  accuracy  of  his  transcript.  Although  he  supplied 
me  with  a  type-written  copy  within  a  few  days  of  the  delivery 
of  each  lecture,  yet  the  pressure  of  other  engagements,  and  the 
difficulty  of  finding  sufficient  continuous  time  to  obtain  and 
arrange  the  illustrations  and  prepare  the  manuscript  for  press, 
has  caused  an  interval  of  more  than  three  years  to  elapse 
between  the  delivery  of  the  lectures  and  their  appearance  in 
print.  During  this  interval  some  new  instruments  for  meas- 
uring the  blood  pressure  in  man  have  been  brought  out,  and 
several  of  them  have  been  described  in  an  appendix. 

Owing  to  my  ignorance  of  the  rule  that  lectures  delivered 
under  the  auspices  of  the  University  and  printed  with  its 
sanction  should  be  published  by  Mr.  Murray,  these  lectures 
were  at  first  advertised  to  be  published  by  Messrs.  Macmillan, 
who  have  published  my  other  works,  and  the  change  was  only 
made  in  accordance  with  the  rule. 

I  have  to  thank  both  Mr.  Murray  and  Messrs.  Macmillan 
for  their  kindness  and  courtesy  in  regard  to  publication,  and 
my  thanks  are  especially  due  to  Professor  Waller  for  his  in- 
terest and  help,  to  Mr.  Syme  for  assistance  in  experiments,  to 
Dr.  Oliver,  M.  Boulitte,  Messrs.  Down,  Mr.  Hawksley,  and 
especially  to  M.  Charles  Verdin  for  many  illustrations. 

Professor  Kronecker  has  kindly  supplied  some  most  valuable 
notes  of  some  of  his  own  work  and  that  of  his  scholars,  which 
is  printed  in  a  special  appendix. 


CONTENTS 


LECTURE   I 

Introduction — Harvey's  Discovery — PHYSIOLOGY  OF  THE  CIRCULATION  : 
—The  Heart — Sleep  of  the  Heart — The  Arteries — Motor  and 
Peristaltic  Action  of  the  Arteries — Capillaries  and  Veins — Action 
of  Fasciae — Accessory  Muscles  of  Circulation — Flow  of  Lymph 
— Arterial  Tension  or  Blood  Pressure — Regulation  of  Blood 
Pressure — Heart  and  Blood  Pressure — Arteries  and  Blood  Pres- 
sure— Influence  of  the  Muscular  Area — Influence  of  the  Splanch- 
nic Area — Distension  of  Liver — Depressor  Nerves — Independent 
Pulsation  of  Veins — Movements  of  the  Heart — Views  of  Gaskell 
— Comparison  between  the  Heart  and  a  Medusa — Experiments 
of  Romanes — Transmission  of  Stimuli  in  the  Heart — Nervous 
and  Muscular  Conduction  in  the  Heart — Experiments  of  Brunton 
and  Cash — Conduction  of  Impulses  both  by  Muscle  and  Nerve — 
Valves  of  the  Heart I 

LECTURE   II 

Sounds  of  the  Heart — Double  Nature  of  the  Heart — Right  Ventricle 
— Aorta — Arteries  and  Capillaries — Vaso-motor  Nerves — Dilating 
Nerves — Elongation  of  the  Muscle  (  ?) — Rhythmical  Contraction 
of  Vessels — Stimulation  of  Vessels  from  without — Stimulation 
of  Vessels  from  within — Effect  of  Heat  and  Cold  on  the  Cir- 
culation— Effect  of  Heat  and  Cold  on  the  Pulmonary  Capillaries 
— Schema  of  the  Circulation — Kymographs — Blood  Pressure  in 
Animals — Blood  Pressure  in  Man — Measurement  of  the  Blood 
Pressure  in  Man — Instruments  for  Measuring  the  Blood  Pres- 
sure in  Man:  by  Pressure  on  an  Artery;  by  Pressure  on  a  Finger 
or  Limb ;  Sphygmomanometers  of  Herisson,  Waller,  Von  Basch, 
Potain,  and  Oliver — Instruments  of  Marey,  Mosso,  Gaertner,  and 
others  41 

LECTURE  III 

Measurement  of  the  Blood  Pressure  in  Man  (continued).  Instru- 
ments of  Riva-Rocci,  Hill  and  Barnard,  Martin,  and  others — 
Author's  arrangement — Standardization  of  Instruments — Meas- 
urement of  the  Size  of  an  Artery — Olivers  Arteriometer — Meas- 


CONTENTS 

urement  of  Pressure  in  the  Veins — Measurement  of  Pressure 
in  the  Capillaries — Measurement  of  the  Volume  of  Organs — 
Plethysmographs  —  Cardiographs  —  Sphygmographs  —  Forms  of 
Sphygmograph :  Marey's,  Ludwig  and  Von  Prey's,  Dudgeon's, 
Jacquet's,  Laulanie's — Size  of  Vessels — Cardiograph  and  Sphyg- 
mograph— Sphygmograms — Retardation  of  Pulse-Wave — Nutri- 
tion of  the  Heart — Self-massage  of  the  Heart — Briicke's  View — 
Nutritive  Action  of  Cardiac  Tonics — Self-massage  of  the  Arteries. 
PATHOLOGY  OF  THE  CIRCULATION  :  Effect  of  Altered  Quality  of 
Blood — Blocking  of  Coronary  Arteries — Effect  of  Feebleness  of 
the  Heart  on  the  Nutrition  of  Blood- Vessels — Nervous  Depression 
— Fatty  Degeneration — Pulse-rate — Exophthalmic  Goitre 77 


LECTURE  IV 

Paroxysmal  Tachycardia — Bradycardia — Intermittent  Pulse — Palpita- 
tion— Shock — Anaesthetics — Syncope — Embolism  and  Throm- 
bosis— Claudication — Angina  Pectoris — Raynaud's  Disease — Chil- 
blains, Urticaria,  Angio-neurotic  (Edema — Migraine — Sensitive- 
ness of  Arteries — Sensitiveness  of  the  Heart.  VALVULAR  DISEASES 
OF  THE  HEART  :  Aortic  Obstruction — Aortic  Regurgitation — Fail- 
ing Compensation — Mitral  Incompetence  (Functional) — Cardiac 
Strain  108 

LECTURE   V 

Mitral  Regurgitation  (Organic) — Mitral  Obstruction — Card'ac  Dys- 
pnoea— Venous  Engorgement — Other  Forms  of  Cardiac  Diseases — 
Vicious  Circle.  METHOD  OF  TREATMENT  IN  CARDIAC  DISEASE: 
Uses  of  Treatment — Rest — Position — Use  of  Massage — Effect  of 
Flatulence  on  the  Heart — Use  of  Drugs  in  Cardiac  Disease — 
Cardiac  Nutrients — Digitalis  and  its  Congeners — Resume  of  the 
Action  of  Digitalis 127 

LECTURE  VI 

Action  of  Digitalis  in  Mammals — Uses  of  Digitalis — Action  of  Digi- 
talis on  CEdema — Toxic  Action  of  Digitalis — Action  of  Digitalis 
on  Arterioles— Stages  in  tbe  Action  of  Digitalis — Difference  be- 
tween Digitalis  and  other  Cardiac  Tonics — Action  of  Adrenaline 
on  the  Heart  and  Vessels — Action  of  Strychnine  on  the  Heart — 
Action  of  Caffeine  and  other  Purin  Bodies — Drawbacks  to  the 
Action  of  Digitalis  and  other  Cardiac  Tonics — Removal  of  these 
Drawbacks  by  Combination — Vaso-dilators :  Amyl  Nitrite,  Iso- 
butyl  Nitrite,  Hydroxylamine,  Nitroglycerine,  Nitro-erythrite, 
Nitromannite,  Sodium,  and  other  Nitrites 149 


CONTENTS  XI 


LECTURE  VII 

Nicotine — Tobacco  Smoking — Attractions  of  Smoking — Results  of 
Excessive  Smoking — Aconite — Local  Modification  of  the  Circu- 
lation— Inflammation — General  Bleeding — Local  Bleeding.  TREAT- 
MENT OF  CARDIAC  DISEASES  :  Treatment  of  Palpitation — Diet  and 
Regimen — Graves's  Disease — Tachycardia  from  Strain — Parox- 
ysmal Tachycardia 167 


LECTURE   VIII 

Bradycardia — Irregularity  of  Pulse — Angina  Pectoris — Treatment  of 
an  Attack  of  Angina  Pectoris — Diet  and  Regimen  in  Angina — 
Cardiac  Asthma — Sleeplessness— Aortic  Disease — Mitral  Regur- 
gitation — Nauheim  Treatment — Exercises — Baths — Oertel's  Treat- 
ment— Treatment  of  Venous  Stasis — Graduated  Exercises — Elim- 
ination— Milk  Diet — Chloride-free  Food  —  Tapping  —  Surgical 
Treatment  of  Cardiac  Diseases — Senile  Rise  of  Pressure — Senile 
Decay — Prolongation  of  Life i85 

APPENDIX  A  211 

APPENDIX  B  216 

APPENDIX  C  223 

APPENDIX  D 225 

INDEX    233 

INDEX  TO  APPENDIX   267 

CLASSIFIED  LIST  OF  ILLUSTRATIONS  ACCORDING  TO  SUBJECTS 271 

LIST  OF  ILLUSTRATIONS  IN  NUMERICAL  ORDER 277 


THERAPEUTICS  OF  THE 
CIRCULATION 


LECTURE    I 

Introduction — Harvey's  Discovery — Physiology  of  the  Circulation — The 
Heart — Sleep  of  the  Heart — The  Arteries — Motor  and  Peristaltic  Action 
of  the  Arteries — Capillaries  and  Veins — Action  of  Fasciae — Accessory 
Muscles  of  Circulation — Flow  of  Lymph — Arterial  Tension  or  Blood  Pres- 
sure— Regulation  of  Blood  Pressure — Heart  and  Blood  Pressure — Arteries 
and  Blood  Pressure — Influence  of  the  Muscular  Area — Influence  of  the 
Splanchnic  Area — Distension  of  Liver — Depressor  Nerves — Independent 
Pulsation  of  Veins — Movements  of  the  Heart — Views  of  Gaskell — Com- 
parison between  the  Heart  and  a  Medusa — Experiments  of  Romanes — 
Transmission  of  Stimuli  in  the  Heart — Nervous  and  Muscular  Conduction 
in  the  Heart — Experiments  of  Brunton  and  Cash — Conduction  of  Impulses 
both  by  Muscle  and  Nerve — Valves  of  the  Heart. 

THE  subject  of  these  lectures  is  "  The  Therapeutics  of  the 
Circulation  " :  the  means  by  which  we  can  put  right  anything 
that  may  have  gone  wrong  with  the  circulation.  If  I  were  to 
hand  my  watch  to  any  one  of  you,  and  tell  you  that  it  was  not 
going  properly,  you  would  naturally  hand  it  back  to  me  and 
tell  me  to  take  it  to  a  watchmaker ;  because  you  know  nothing 
of  the  way  in  which  watches  are  built,  of  the  disorders  to 
which  they  are  liable,  or  the  way  in  which  to  put  them  right. 
In  the  same  way,  before  you  can  put  anything  right  which  has 
gone  wrong  with  the  circulation,  you  must  know  something 
about:  (i)  its  normal  working,  or  physiology;  (2)  of  the  dis- 
orders to  which  it  is  liable,  or  pathology ;  ( 3 )  of  the  means  by 
which  we  can  act  upon  it,  or  pharmacology;  (4)  of  the  indi- 
cations by  which  we  recognize  the  particular  disorder,  or 
semeiology;  and  (5)  the  methods  of  applying  our  remedies  to 
the  disorders  which  we  have  already  recognized,  or  thera- 
peutics. 


2  THERAPEUTICS    OF    THE    CIRCULATION 

It  is  evident  that,  before  we  can  deal  with  therapeutics  satis- 
factorily, we  must  take  up,  to  a  certain  extent,  the  other  sub- 
jects upon  which  it  depends,  and,  although  you  have  studied 
them  all  to  a  certain  extent  already,  I  think  it  will  be  advisable 
to  go  shortly  over  them,  more  especially  as  I  shall  have  to  take 
them  in  definite  relation  to  their  practical  use,  instead  of 
merely  considering  them  as  scientific  subjects  unconnected, 
possibly,  with  practical  medicine.  But  the  treatment  of  these 
must  necessarily  be  very  brief,  because  the  subject-matter  to 
be  considered  is  very  great. 

Harvey's  Discovery. — There  is,  perhaps,  no  discovery, 
either  ancient  or  modern,  which  has  had  such  a  -far-reaching  in- 
fluence on  the  health  of  human  beings  as  the  discovery  by  Har- 
vey of  the  circulation.  The  truth  of  this  discovery  was  at  first 
denied,  then  its  importance  was  belittled,  then  it  was  attributed 
to  other  men;  but  now  its  full  importance  is  recognized  and 
the  claims  of  Harvey  to  the  discovery  acknowledged.  When 
we  look  at  Harvey's  work,  it  seems  almost  incredible  that  for 
so  many  thousands  of  years  men  should  have  overlooked  the 
circulation.  When  we  read  Harvey's  own  account  of  his 
discovery,  it  seems  one  of  such  amazing  simplicity  that  one  is 
inclined  to  think  that  nobody  could  have  helped  making  it.  In 
his  own  words,  it  occurred  to  him  "  whether  the  blood  might 
not  go  round,  as  it  wrere,  in  a  circle."  That  it  did  go  round, 
Harvey  showed  by  the  blood  issuing  from  the  proximal  end 
of  a  cut  artery,  and  from  the  swelling  of  the  veins  when 
obstruction  was  put  between  the  periphery  and  the  centre. 

One  of  the  great  reasons  why  the  blood  had  been  supposed 
not  to  go  round,  but  to  flow  backwards  and  forwards,  probably 
was  that  the  ancients  looked  upon  the  arteries  as  conveying  air 
alone  instead  of  blood,  or  else  conveying  a  mixture  of  air  and 
blood.  They  seem  to  have  come  to  this  conclusion  from  the 
fact  that  the  arteries  were  generally  found  empty  in  animals 
that  had  been  killed  for  sacrifice,  and  the  reason  of  this  empti- 
ness I  shall  discuss  later  on. 


SLEEP  OF  THE  HEART  3 

PHYSIOLOGY  OF  THE  CIRCULATION 

The  Heart. — The  great  motor  power  which  keeps  the  cir- 
culation moving  in  a  circle  is  the  heart,  although  its  action  is 
supplemented  by  other  mechanisms  in  the  vessels  and  tissues. 
We  are  sometimes  accustomed  to  speak  of  this  "  unresting  " 
organ,  but  this  is  a  total  mistake.  The  heart  rests  in  an  adult 
more  than  thirteen  hours  out  of  the  twenty-four;  the  time  of 
rest  being  the  diastole,  and  the  time  of  work  being  the  systole. 
Sleep  of  the  Heart. — We  may  say,  then,  that  the  heart 
practically  sleeps  more  than  the  brain  or  the  body ;  but  the  great 
distinction  between  the  sleep  of  the  heart  and  that  of  the  brain, 
is  that  the  sleep  is  so  short  at  a  time.  There  are  very  few 
healthy  men  who  could  not  walk  a  thousand  miles  in  six  weeks, 
walking  a  little  over  eight  hours  a  day  at  an  easy  pace,  and 
resting  for  the  remainder  of  the  period ;  but  there  are  not  many 
men  who  could  emulate  the  feat  of  Captain  Barclay,  of  walk- 
ing a  thousand  miles  in  a  thousand  hours,  because  the  frequent 
interruptions  to  their  sleep  would  exhaust  them  completely; 
and  still  fewer  are  there  who  could  walk  a  thousand  miles  in  a 
thousand  half-hours,  as  has  been  done  by  various  men  since 
Captain  Barclay's  time.  In  such  trials  of  endurance  a  man 
usually  walks  two  miles  at  a  time,  the  first  mile  at  the  end  of 
one  hour  or  half -hour,  and  the  second  at  the  beginning  of  the 
next  hour  or  half -hour.  Supposing  he  walks  at  the  rate  of 
four  miles  an  hour,  i.  e.  a  mile  in  a  quarter  of  an  hour,  he  gets 
an  hour  and  a  half  for  sleep  between  every  walk  when  doing  a 
thousand  miles  in  a  thousand  hours,  but  only  gets  one-third  as 
much  sleep,  viz.  half  an  hour,  between  his  walks  when  doing 
this  distance  in  a  thousand  half-hours.  An  attempt  to  do  a 
thousand  miles  in  a  thousand  quarter-hours  is  obviously  im- 
possible;— if  a  man  walked  at  the  rate  of  four  miles  an  hour, 
there  would  be  no  time  for  rest  at  all,  the  whole  time  being 
required  for  walking.  A  little  time  might,  no  doubt,  be  gained 
by  increasing  the  pace;  but  this  would  itself  involve  greater 
exertion,  and  the  time  thus  gained  would  be  quite  insufficient 
for  recuperation. 


4  THERAPEUTICS    OF    THE    CIRCULATION 

In  the  same  way,  when  the  heart  is  forced  to  beat  more 
quickly  than  normal,  it  is  more  and  more  quickly  exhausted  the 
higher  the  pulse-rate  rises,  for  nearly  the  whole  time  for  the 
extra  work  is  taken  from  the  diastolic  pauses  of  sleep  of  the 
heart,  even  though  the  systole  may  be  slightly  shortened. 
Hence  the  importance  of  slowing  the  pulse-rate  by  cold,  by 
drugs,  or  by  other  measures,  when  it  tends  to  become  too  rapid. 

Perhaps  it  may  be  as  well  here  that  I  should  note  that  the 
heart,  at  certain  periods,  is  resistant  to  external  stimuli.  When 
Captain  Barclay  was  taking  his  sleep  between  his  walks,  he 
would  be  more  and  more  ready  to  respond  to  a  chance  call  the 
nearer  the  time  came  for  him  to  begin  again ;  but  while  actually 
engaged  in  his  walk,  he  would  be  too  much  intent  upon  his 
work  to  heed  a  call  from  anyone.  In  the  same  way,  we  find 
that  during  the  period  that  the  heart  is  contracting  it  will  not 
respond  to  a  stimulus  which,  if  applied  immediately  after  its 
action  is  over,  would  cause  it  to  contract  again.  This  period, 
which  we  have  to  consider  later  on,  is  called  the  refractory 
period. 

The  Arteries. — Now,  if  the  heart  is  only  acting  for  eleven 
hours  out  of  the  twenty- four,  and  is  entirely  cut  off  from  the 
aorta  by  the  closed  aortic  valves,  what  force  is  carrying  on  the 
circulation  during  the  whole  of  the  other  thirteen?  This  force 
is  the  elastic  recoil  of  the  arteries,  which  have  been  stretched 
by  the  blood  forced  into  them  during  the  ventricular  systole, 
but  which,  if  healthy,  again  contract  during  the  diastole.  The 
vessels  thus  act  as  storage  of  energy,  just  as  a  watch-spring 
does  when  wound  up  every  night,  or  as  the  water  driven  by  a 
force-pump  into  a  high  tank  from  which  a  house  or  town  can 
be  supplied,  or  the  elastic  bag  in  a  spray-producer. 

The  arteries  have  really  three  functions.  They  not  only  act 
as  (i)  storers  of  force,  but  as  (2)  regulators,  and  as  (3) 
motors.  Their  power  of  regulating  the  supply  of  blood  to 
different  parts  of  the  body  was  known  to  Harvey,  who  said : — 
"  It  is  manifest  that  the  blood  in  its  course  does  not  every- 
where pass  with  the  same  celerity,  neither  with  the  same  force 


ACTION    OF    ARTERIES,    CAPILLARIES    AND    VEINS  5 

in  all  places,  and  at  all  times.  ...  In  fear,  and  under  a  sense 
of  infamy  and  of  shame,  the  face  is  pale;  but  the  ears  burn,  as 
if  for  the  evil  they  heard  or  were  to  hear."  As  my  old  teacher, 
Professor  Ludwig,  used  to  put  it,  "  There  is  not  nearly  suffi- 
cient blood  in  the  body  to  fill  all  the  vessels  at  once,  and  the 
vaso-motor  system,  which  regulates  the  size  of  the  arteries, 
is  like  the  turncock  in  a  large  town  who  turns  off  the  water 
supply  to  one  district  at  the  same  time  that  he  turns  it  on  to 
another;  just  as  in  Harvey's  "  observation,  the  vessels  became 
contracted  in  the  face  at  the  same  time  as  they  became  dilated 
in  the  ear. 

Motor  and  Peristaltic  Action  of  Arteries. — The  motor 
action  of  the  arteries  has  received  less  attention;  but  it  is,  I 
think,  very  important,  and  is,  I  believe,  the  cause  of  the  empti- 
ness of  the  arteries  after  death,  which  so  long  prevented  Har- 
vey's discovery  from  being  made.  When  working  under  Pro- 
fessor Lu.dwig  in  1869,  he  directed  my  attention  to  the  con- 
tractile power  of  the  small  arteries  apart  from  any  nerve  centre, 
and  while  watching  their  movements  I  have  sometimes  seen  a 
regular  peristaltic  action  take  place,  by  which  the  blood  was 
driven  forward  in  the  arteriole,  just  as  faecal  matter  would 
be  driven  forward  in  the  intestine.1 

Capillaries  and  Veins. — From  the  arteries  the  blood  passes 
into  the  capillaries,  and  some  of  its  liquid  parts  leak  through 
their  walls  to  supply  the  needs  of  the  tissues,  while  the  remain- 
der, along  with  the  blood  corpuscles,  passes  into  the  veins.  It 
is  the  heart  which  is  the  motor  power  for  the  blood  in  the 
veins  also ;  but  it  could  barely  be  sufficient  to  carry  on  the  cir- 
culation and  bring  the  blood  back  to  the  heart  again,  were  it 
not  for  various  helping  agencies.  One  of  these  is  the  suction 
exerted  by  the  movements  of  the  respiration,  and  another  is 
the  suction  exerted  by  the  heart  itself  during  the  ventricular 
contraction,  which  drives  the  blood  out  of  the  thorax,  through 
the  aorta,  and  sucks  it  in  through  the  veins. 

1  Lauder  Brunton,  Sitz.  her.  d.  k.  sack.  Gescllsch.  d.  Wiss.,  1869,  s.  285, 
and  Ludivig's  Arbeiten,  1869,  s.  101. 


One  very  important  adjunct  to  the  heart  in  keeping-  up  the 
venous  circulation,  is  intermittent  pressure  upon  the  veins 
from  without,  aided  by  numerous  valves  in  the  veins  them- 
selves; so  that  while  each  pressure  pushes  the  blood  a  little 
onwards,  its  return  is  prevented.  External  pressure  is  pro- 
duced by  muscular  action.  Each  contraction  of  a  muscle 
squeezes  the  blood  and  also  the  lymph  out  into  the  veins  and 
lymphatics,  both  of  which  have  very  numerous  valves  at  short 
distances  apart.  But  every  beat  of  the  arteries,  as  a  rule, 
tends  also  to  help  on  the  venous  blood,  for  the  arteries  and 
veins  usually  have  a  common  sheath  of  unyielding  fibrous 
tissue,  and  each  time  that  the  artery  is  distended  during  a 
ventricular  systole  it  tends  to  push  a  corresponding  amount  of 
blood  onwards  through  its  accompanying  vein.  (Fig.  i.) 


1'lG.  i.  Diagram  to  show  the  effect  of  the  arterial  pulse  in  aiding  the  onward  flow 
of  venous  blood  and  lymph,  by  a  process  of  what  may  be  called  self-massage.  A  is 
an  artery  during  diastole.  V  is  a  vein  filled  with  blood.  5  is  the  fibrous  sheath  which 
encloses  the  artery,  the  vein,  and  the  lymph  space  around  them.  A'  is  the  artery 
distended  with  blood  by  the  ventricular  systole.  As  the  sheath  S'  is  unyielding,  the 
distension  of  the  artery  forces  the  blood  out  of  the  vein  and  the  lymph  out  of  the 
lymph  space,  and  as  the  backward  flow  of  both  is  prevented  by  the  valves  of  the 
veins  and  lymphatics,  the  circulation  is  increased  in  both. 

Action  of  Fasciae. — In  addition  to  these  mechanisms,  how- 
ever, we  have  the  pressure  upon  the  veins  by  the  fascine  of 
the  limbs,  and  Braune  has  shown  that  when  the  veins  are 
stretched,  their  walls  tend  to  come  together  and  press  the  blood 
onwards.  The  veins  of  the  upper  limbs  are  most  stretched 
when  the  fists  are  clenched,  the  hands  bent  somewhat  down, 
and  the  arms  extended  and  pushed  rather  backwards — the  very 
attitude,  indeed,  that  is  assumed  by  a  man  who  has  been  sitting 
for  a  length  of  time  at  a  writing-table  and  feels  himself 
cramped  in  consequence.  The  veins  become  filled  when  the  leg 
is  bent  and  turned  slightly  inwards,  whilst  the  veins  become 
stretched  and  empty  when  the  foot  is  turned  outwards  and  the 


ACCESSORY    MUSCLES    OF    CIRCULATION  7 

leg  extended  and  pushed  somewhat  backward.  The  first  of 
these  positions  is  that  assumed  by  one  leg  when  we  advance 
it  for  the  purpose  of  walking,  and  the  second  when  we  move 
the  body  and  other  leg  forward. 

Accessory  Muscles  of  Circulation. — The  late  Professor 
Sharpey  used  to  insist  a  good  deal  upon  the  functions  of  the 
rotators  of  the  leg,  and  he  pointed  out  that  in  books  on  anat- 


FIG.  2.  Diagram  of  transverse  section  of  voluntary  muscle  to  show  the  pumping 
action  exerted  on  the  muscle-juice  and  waste  products  during  action.  The  blood- 
vessels cross  diagonally.  To  the  left  (B)  the  muscle  is  contracted  and  presses  the 
two  layers  of  the  fascia  together,  so  as  to  drive  the  muscle-juice  out  into  the 
lymphatics.  To  the  right  (A)  the  muscle  is  relaxed,  and  tends  to  draw  the  layers  of 
fascia  apart  and  suck  the  juice  out  of  the  muscle  into  the  lymph  space,  c,  Artery. 
d,  Artery,  e,  Lymphatics.  /,  Vein,  g,  Vein.  The  double  arrows  in  A  are  intended 
to  indicate  the  increased  blood-flow  through  the  muscle,  and  the  single  arrow  within 
the  muscle  to  indicate  the  passage  of  fluid  from  the  muscle  into  the  lymph  space 
between  it  and  the  surrounding  fascia. 

omy  the  trunk  is  looked  upon  as  a  fixed  point,  and  the  rotation 
is  discussed  in  terms  of  this;  so  that  we  say  that  the  function 
of  the  tensor  vaginae  femoris  is  to  rotate  the  leg  inwards  upon 
the  body,  and  that  of  the  glutens  maximus  to  rotate  it  out- 
wards. In  reality,  he  said  it  is  the  leg  which  is  the  fixed  point 


8 


THERAPEUTICS    OF   THE    CIRCULATION 


in  walking;  and  the  function  of  these  muscles  is  to  rotate  the 
body  on  the  leg,  the  tensor  vaginae  femoris  rotating,  not  the 
leg  inwards,  but  the  body  outwards,  so  as  to  bring  the  centre 


FIG.  3.  Diagram  of  longitudinal  sections  of  muscles,  I.  in  relaxation  and  II.  in 
contraction.  F  is  the  fibrous  fascia  or  sheath  of  the  muscle.  L  S  a  lymph  space 
between  the  muscle  and  the  outer  layer  of  fascia.  L  is  a  lymphatic  vessel  with 
numerous  valves,  by  which  the  lymph  containing  waste  products  is  removed.  A  is 
an  artery  by  which  fresh  blood  is  brought  to  the  muscle;  and  V  is  A  vein  by  which 
blood  is  removed  from  it.  Each  time  the  muscle  contracts,  as  in  II.,  it  lessens  the 
size  of  the  lymph  space  and  drives  the  lymph  onward  through  the  lymphatics. 
Each  time  it  relaxes  it  tends  to  create  a  vacuum  within  the  fascia,  and  thus  lymph 
is  sucked  out  of  the  muscle  into  the  lymph  space,  while  fresh  arterial  blood  rushes 
into  the  muscle. 


FIG.  4.  Injected  lymph  spaces  from  the  fascia  lata  of  the  dog,  after  Ludwig  and 
Schweigger-Seidel,  Lymphgefasse  der  Fascien  und  Sehnen.  The  injected  spaces  are 
black  in  the  figure,  and  the  muscular  bundles  are  seen  in  the  cross-section  embedded 
in  lymph. 

of  gravity  over  the  foot.  But  in  view  of  Braune's  observations 
these  muscles  acquire  a  new  value.  We  speak  very  frequently 
of  accessory  muscles  of  respiration,  but  I  have  not  seen  any- 


FLOW    OF    LYMPH  9 

where  the  tensor  vaginae  femoris  and  the  gluteus  maximus 
spoken  of  as  accessory  muscles  of  circulation,  yet  both  they 
and  the  muscles  of  the  calf  and  thigh  may  well  deserve  such 
an  appellation. 

Flow  of  Lymph. — This  description  of  the  circulation,  how- 
ever, would  be  insufficient  without  a  consideration  of  how  the 
lymph  flows,  for  the  circulation  of  lymph  is  quite  as  necessary 
as  that  of  the  blood  itself.  Here  also  the  muscles  form  one  of 
the  most  efficient  sources  of  motor  power.  At  each  relaxation 
of  a  muscle  it  tends  to  cause  a  vacuum  within  its  surrounding 


FIG.  5.  Section  of  the  central  tendon  of  the  diaphragm  in  the  rabbit,  a,  Peri- 
toneum; b,  tendinous  fibers  in  cross-section;  c,  circular  fibers;  d,  the  pleura;  e,  peri- 
toneum stretched  over  a  full  lymph  space;  /,  peritoneum  lying  in  an  empty  lymph 
space;  g,  blood-vessels.  After  Ludwig  and  Schweigger-Seidel. 


FIG.  6.     Section  of  the  pleura.     The  lymph  spaces  appear  black  in  the  figure.     After 
Ludwig  and   Dybkowsky. 

fascia,  into  which  the  lymph  flows  from  the  muscular  struc- 
ture. At  each  contraction  the  muscle  presses  this  lymph  out, 
and  these  alternating  muscular  movements  really  act  as  a  sub- 
sidiary heart,  and  do  away  with  the  necessity  of  having  in 
mammals  the  lymph  hearts  which  are  seen  in  the  frog.  (Figs. 
2,  3,  and  4.) 

In  the  pleura  and  the  diaphragm  the  movements  of  respira- 
tion have  a  similar  pumping  action  on  the  pleural  and  peri- 
toneal fluids.  (Figs.  5  and  6.) 


IO  THERAPEUTICS    OF    THE    CIRCULATION 

It  may  seem  that  I  am  spending-  too  much  time  upon  points 
in  the  circulation  which  you  all  know,  but  I  shall  have  to  return 
to  them  again  in  discussing  Treatment,  and  unless  I  had  put 
them  before  you  now  in  the  way  I  have  done,  you  might  not 

be  so  readily  able  to  perceive 
the  reason  for  the  therapeutic 
measures  which  I  shall  after- 
wards have  to  mention. 

Arterial  Tension  or  Blood 
Pressure. — During  the  long 
sleep  of  the  heart — thirteen 

FIG.  7.  Diagram  of  the  circulation.  hours  OUt  of  CVCry  twenty-four 
a,  the  heart  completely  shut  off  by  the  ,1  •  i  ,  •  •  •  ,  •  j 

valves   during   diastole    from   b,   the     — the  circulation  is  maintained 

arteries;  c,  the  capillaries;  d,  the  veins;       by    the    COlltraCtile    force    of    the 

e,   mercurial    manometer;    /,    a   float;   g,  .  1-1 

a    recording    cylinder.  artCriCS,  which  prCSSCS  the  blood 

out  through  the  only  opening 

which,  in  health,  is  available,  namely  through  the  capillaries. 
This  contractile  force,  is,  of  course,  to  a  great  extent,  due  to 
elasticity,  especially  in  the  larger  arteries,  although  in  the 
arterioles  it  is  probably  partly  due  to  contractility.  The  force 
with  which  the  blood  would  be  pressed  out  if  a  vessel  were 
opened  or  a  cannula  put  into  it,  is  known  as  the  blood  pressure, 
and  this  is  usually  estimated  by  connecting  an  artery  with  a 
mercurical  manometer  and  seeing  the  height  of  mercury  re- 
quired to  counterbalance  the  pressure  in  the  vessels.  This  was 
first  estimated  by  a  clergyman,  the  Reverend  Stephen  Hales,1 
wrho,  after  cutting  an  artery  in  an  animal,  and  after  connect- 
ing a  glass  tube  with  the  artery,  noted  the  height  to  which  the 
blood  rose  in  the  tube.  Poiseuille2  improved  upon  this  plan 
by  connecting  the  artery  with  a  mercurial  manometer,  and  an 
immense  advance  was  made  by  Ludwig,3  who  registered  the 
movements  of  a  manometer  on  a  revolving  cylinder.  (Fig.  8.) 

1  Hales,  Statistical  Essays,  London,  1733,  vol.  ii.,  p.  i. 

2  Poiseuille,  Magcndic's  Journ.   de   la  physiol,  viii.,   p.   272,    1828;    ix., 
1829,  p.  343. 

3  Ludwig,  Arch.  f.  Anat.  u.  Physiol.,  1847,  s.  242,  Taf.  x.-xiv. 


ARTERIAL    TENSION1    OR    BLOOD    PRESSURE 


I  I 


Although  he  did  this  in  1847,  7et  m  1865,  when  I  first  began 
to  work  at  the  action  of  drugs  on  the  blood  pressure,  there 
was,  I  believe,  not  a  single  recording  manometer  in  this  coun- 


FIG.  8.  Ludwig's  kymograph,  a  b  c  is  a  simple  mercurial  manometer  such  as 
was  used  by  Poiseuille.  c  b  and  g  are  the  float,  and  h  the  recording  cylinder,  and 
t  the  clockwork  added  by  Ludwig. 

try.1  and  it  was  only  at  this  time  that  one  was  first  made  by 
Sir  John  Burdon-Sanderson,2  and  used  by  him  in  his  research 

1  Lauder  Brunton,  "  On  Digitalis,"  Collected  Papers  on  Circulation  and 
Respiration.     First  Series,  pp.  52  and  104.     London :  Macmillan  &  Co. 

2  Burdon-Sanderson,   Roy.   Soc.   Proc.,   xv.,    1857,   p.   391;   Phil.   Trans.. 
clvii.,  1867.  p.  391. 


12 


THERAPEUTICS    OF    THE    CIRCULATION 


FIG.  9.  Lelaunie's  manometer.  It  consists  of  (7")  a  bent  tube  containing  mercury. 
The  open  arm  bears  a  float,  the  movements  of  which  are  transmitted  by  a  pulley  (P) 
to  the  lever  (L),  which  amplifies  and  records  them.  By  means  of  a  pinion  (B)  work- 
ing 011  a  rack  (C),  the  apparatus  can  be  moved  up  and  down  on  a  stand  (5),  which 
is  rendered  vertical  by  three  screws  (V  V  V).  The  open  end  of  the  tube  can  be 
connected  with  a  caoutchouc  bag,  as  in  the  figure.  It  was  originally  designed  to- 
record  the  rectal  temperature  in  a  dog  during  tetanization,  but  it  could  be  used  for 
other  purposes.  Burdon-Sanderson's  kymograph  was  similar  to  this,  but  the  two 
limbs  of  the  U  tube  were  of  unequal  width,  and  the  lever  was  longer. 


Carotid  artery  (full)  • 


Aorta  tense ^.^....^ 

Veins  tense  and 
moderately  full  — 


Bladder  (full) 


Carotid  artery  (empty). 


Aorta  lax. 

._  Veins  lax  and  full. 


Bladder  (empty). 


FIG.  10.  Diagram  to  show  the  causation  of  syncope.  In  a  the  carotid  artery  is 
full,  the  aorta  full,  the  veins  contracted,  and  the  bladder  is  full.  In  b  the  carotid  is. 
empty,  so  that  the  brain  is  insufficiently  supplied  with  blood,  and  syncope  ensues. 
The  tension  in  the  aorta  is  low,  as  indicated  by  its  smaller  size,  the  veins  are  full, 
and  the  bladder  is  empty. 


MEASUREMENT    OF    BLOOD    PRESSURE 


upon  the  relationship  of  respiration  to  circulation.  It  was  just 
a  little  before  this  that  Marey1  invented  his  sphygmograph, 
by  which  much  interesting  information  has  been  gained  re- 
garding the  circulation  in  man.  (Fig.  120.) 


Inhibitory  apparatus 
Motor  ganglia 

Heart  muscle 


^•••••••••••••l^BMMM^MH 

FIG.  ii.  Diagram  to  show  the  nervous  apparatus  by  which  the  action  of  the  heart 
and  vessels  is  coordinated  so  as  to  maintain  an  equal  blood  pressure.  A  is  the 
accelerator  apparatus. 


accelerator  apparatus 

Regulation  of  Blood  Pressure. — The  blood  pressure,  one 
may  roughly  say,  depends  upon  the  difference  between  the 
1  Marey,  Mem.  Soc.  Biol.,  1859,  p.  281;  Compt.  rend.,  1880,  1.,  p.  634. 


14  THERAPEUTICS    OF    THE    CIRCULATION 

amount  pumped  by  the  heart  into  one  end  of  the  arterial  sys- 
tem and  the  amount  leaving  by  the  capillaries  in  any  given 
time.  It  is  obvious  that  unless  some  means  existed  by  which 
these  two  factors  could  be  brought  into  proper  relationship. 


Cord  t  va,gti s  irrita.fced- 


VdguS 
alone 


FIG.  12.  After  Ludwig.  Ludwig's  Arbeiten,  187,  p.  106. — Shows  the  rapidity  with 
which  the  blood  flows  through  the  vessels  of  the  muscles.  When  the  heart  is  stopped 
by  irritating  the  vagus  the  arterial  pressure  falls  continuously,  as  the  blood  flows  out 
of  the  arteries  into  the  veins  through  the  vessels  of  the  intestines,  muscle,  and 
brain.  The  higher  the  pressure  the  more  quickly  will  the  blood  flow  through  them, 
and,  other  things  being  equal,  the  quicker  will  the  pressure  fall. 

The  curves  are  taken  from  the  arterial  pressure  in  a  middle-sized  dog  whose 
spinal  cord  had  been  divided  high  up  in  the  neck,  a,  b  and  c  show  the  rapidity  of 
fall  of  blood  pressure  at  various  heights  during  simultaneous  stimulation  of  the  vaso- 
motor  nerves  in  the  spinal  cord  and  stoppage  of  the  heart  by  stimulation  of  the 
vague.  In  d  the  vagus  alone  was  stimulated. 

If  the  assumption  were  correct  that  all  the  arterioles  in  the  body  were  con- 
tracted by  stimulation  of  the  vaso-motor  nerves  in  the  cord,  the  blood  pressure  should 
hardly  fall  at  all  during  stoppage  of  the  heart,  when  the  vaso-motor  center  is  stimu- 
lated at  the  same  time.  But  the  curves  a,  b  and  c,  and  especially  a,  show  that  it 
falls  with  such  rapidity  that  it  must  be  assumed  that  the  blood  flows  through  the 
vessels  of  the  muscles  which  are  not  under  the  same  control  of  the  vaso-motor 
centers  as  those  of  the  intestine. 


much  mischief  might  be  done.  If  the  heart  were  to  continue 
pumping  in  blood  whilst  the  arterioles  were  tightly  contracted, 
the  heart  would  either  become  strained  or  a  vessel  would  burst. 


HEART    AND    ARTERIES    AND    BLOOD    PRESSURE  I  5 

as  it  does  in  apoplexy.  On  the  other  hand,  if  the  arterioles 
were  dilated  and  the  heart  did  not  beat  more  actively  in  order 
to  supply  a  larger  amount  of  blood,  the  arteries  would  very 
likely  become  empty  and  the  pressure  in  them  so  low  that  the 
circulation  through  the  various  organs  would  be  insufficient 
to  maintain  their  functional  activity,  and  the  brain,  being  es- 
pecially sensitive,  syncope  would  result.  (Fig.  10.) 

Heart  and  Blood  Pressure. — Coordination  is  maintained 
by  means  of  the  nervous  system,  the  chief  center  of  which  is 
in  the  medulla  oblongata,  where  the  most  important  part  of  the 
vaso-motor  center  is  located,  and  where  also  the  vagus  roots 
are  situated.  By  irritation  (a)  of  the  vagus  roots  or  (b]  of 
their  trunks,  or  (c)  of  their  ends  in  the  heart,  the  movements 
of  the  heart  become  slower  and  generally  weaker,  although  the 
slowing  and  weakness  may  occur  more  or  less  independently 
of  each  other.  Any  excessive  tension  in  the  vessels,  involving 
as  it  does  the  blood  supply  of  the  medulla,  acts  as  an  irritant  to 
the  vagus  center,  puts  the  vagus  nerve  into  action,  slows  the 
heart,1  and  thus  prevents  the  tension  from  rising  too  high. 
(Fig.  n.)  On  the  other  hand,  diminished  pressure  in  the 
arterial  system  lessens  the  normal  stimulation  of  the  vagus 
center,  and  in  consequence  the  vagus  nerves  act  less  power- 
fully on  the  heart,  its  beats  become  quicker,  and  the  pressure 
rises. 

Arteries  and  Blood  Pressure. — On  the  other  hand  the 
vaso-motor  center  when  in  action  causes  the  arterioles,  es- 
pecially of  the  intestines  and  of  the  skin,  to  contract,  so  that 
the  channels  by  which  the  blood  can  pour  from  the  arteries 
into  the  veins  are  diminished  in  size,  and  the  pressure,  conse- 
quently, tends  to  rise. 

Influence  of  the  Muscular  Area. — There  are,  however,  a 
number  of  arteries  which  are  only  slightly  influenced  by  the 

1This  has  been  shown  in  brain  kept  alive  by  artificial  circulation  and 
separated  from  the  rest  of  the  body,  except  that  the  vagi  remained  intact, 
so  that  the  brain  could  act  on  the  heart. — Francois  Franck,  Trav.  du 
laboratoire  de  Marey,  1877,  vol.  iii.,  p.  276. 


i6 


THERAPEUTICS    OF    THE    CIRCULATION 


Brain 


vaso-motor  center,  for,  when  this  center  is  irritated  so  as  to 

contract  all  the  vessels  of  the 
skin  and  intestines  to  the  ut- 
most, blood  may  still  pour 
through  those  vessels  which 
supply  the  muscles  so  rapidly 
that  the  effect  of  the  vaso- 
motor  centre  hardly  appears 
to  be  felt  at  all.  (Fig.  12.) 
Nevertheless,  Waller  noticed 
that  sometimes  by  stimulating 
this  center  the  tension  may 
rise  so  high  as  to  prevent  the 
heart  from  beating.  These 
different  results  depend,  of 
course,  upon  the  different 
animals  experimented  upon 


Heart 


Intestine 


Muscle 


FIG.   13.     Diagram     showing     the     four  ,       ,  ,.,-.. 

great  areas  for  the  distribution  of  blood  in  and     the     different     COndltlOllS 

the   body,   viz.,   the  muscles,   the   intestine,  uncjer    wniCh    the    experiments 
the    skin,    and    the   brain. 

are  made. 

Influence  of  the  Splanchnic  Area. — The  four  largest 
vascular  districts  in  the  body  are  those  of  (i)  the  splanch- 
nic area,  (2)  the  muscles,  (3)  the  brain,  and  (4)  the  skin. 
(Fig.  13.)  It  is  the  splanchnic  area  which  is  more  especially 
under  the  influence  of  the  vaso-motor  center.  Any  disturb- 
ance of  the  circulation  in  this  area  greatly  modifies  the  blood 
pressure,  and  section  of  the  splanchnic  nerves  will  reduce  it 
enormously.  The  splanchnic  area,  therefore,  serves  to  a  great 
extent  as  a  regulator  of  blood  pressure,  and  when  the  portal 
vein  is  tied,  the  whole  of  the  blood  in  the  body,  or  at  least  a 
large  part  of  it,  will  collect  in  the  vessels  of  the  intestines  and 
in  the  liver ;  so  that,  to  use  Ludwig's  words,  "  an  animal  may 
be  bled  into  its  own  veins." 

In  1868  Ludwig1  and  one  of  his  pupils  made  some  experi- 

'Ludwig  and  Schmulewitsch,  Ludwig's  Arbeiten,  3tier  Jahrg.,  1868, 
p.  114. 


INFLUENCE    OF    SPLANCHNIC    AREA  17 

ments  upon  the  secretion  of  bile  by  an  excised  liver,  through 
which  a  stream  of  blood  was  passed  artificially ;  and  on  making 
experiments  myself  a  year  or  two  later,1  I  was  very  much 
struck  by  the  enormous  distensibility  of  the  liver.  One  is 
misled  in  regard  to  this  property  by  the  hard,  firm  appearance 


Qottle  containing  blood 


Liver. 

Cannula  for  outflow  of 
*"  blood. 

FIG.  14.  Diagram  to  show  the  effect  of  artificial  circulation  of  blood  through  the 
liver,  under  different  pressures.  The  continuous  lines  indicate  the  size  of  the  liver, 
and  the  arrangement  of  the  apparatus  during  circulation,  under  a  low  pressure.  The 
dotted  lines  indicate  the  increased  size  of  the  liver,  and  the  arrangement  of  the 
apparatus,  under  a  high  pressure. 

of  the  liver  after  death;  but  during  life  the  liver  is  more  like  a 
sponge,  and  reacts  just  like  a  sponge  to  the  slightest  difference 
in  blood  pressure,  swelling  up  as  the  pressure  increases,  and 
diminishing  as  the  pressure  falls.  (Fig.  14.) 

Distension  of  Liver. — In  the  healthy  body  we  do  not  notice 
great  changes  in  the  liver,  because  the  pressure  in  the  portal 
system  undergoes  but  very  slight  change.  However,  when 
there  is  backward  pressure  from  the  heart,  in  consequence  of 
incompetency  of  the  tricuspid  Valves,  the  liver  sometimes  be- 
comes enormously  large,  reaching  down  to  the  umbilicus  or 
even  to  the  iliac  fossa. 

Depressor  Nerves. — As  I  have  already  mentioned,  when 
the  tension  is  too  great  in  the  heart  and  aorta,  it  acts  as  a 
stimulus  to  nerves,  starting  from  the  heart  and  aorta,  and 

'Lauder  Brunton,  Bur  don-Sanderson's  Handbook  for  the  Physiological 
Laboratory,  1873,  p.  505  et  seq.,  and  Lettsomian  Lectures,  1885,  in  Dis- 
orders of  Digestion,  p.  25. 


1 8  THERAPEUTICS    OF    THE    CIRCULATION 

causing  reflex  dilatation  of  the  abdominal  vessels;  so  that  the 
tension  in  the  aorta  is  thus  relieved.  These  nerves  may  either 
run  as  a  separate  nerve,  known  as  the  depressor  nerve,  1or  may 
be  partly  incorporated  with  the  vagus  trunk. 

Independent  Pulsation  of  Veins. — All  through  the  veins 
the  circulation  is  steady  and  even;  but  when  we  come  to  the 
vena  cava  and  pulmonary  veins,  we  find  that  these  vessels  may 
have  a  pulsatile  contraction  of  their  own,  like  that  of  the  venous 
sinus  in  the  frog.  This  action  of  the  veins  had  apparently 
been  lost  sight  of  until  Fayrer  and  I  rediscovered  it,2  but  we 
could  not  then  find  any  mention  of  it  in  any  of  the  ordinary 
text-books  on  physiology.3  It  was,  however,  well  known  to 
Haller,4  and  also  to  Senac,5  a  century  and  a  half  ago,  and  we 
have  since  found  it  had  been  noticed  by  Colin6  a  year  or  two 
before  our  observation.  This  contraction  is  not  always  pres- 
ent, and  so  it  can  hardly  be  regarded  as  a  constant  part  of  the 
cardiac  pulsation. 

Movements  of  the  Heart. — Views  of  Gaskell. — In  con- 
sidering the  motion  of  the  heart,  we  begin,  then,  with  the  auri- 
cle, which  contracts  and  drives  the  blood  into  the  empty  ven- 
tricle. The  ventricle  in  turn  drives  the  blood  onwards  into 
its  corresponding  artery.  Formerly,  the  rhythmical  action, 
both  of  auricles  and  ventricles,  and  the  coordination  of  their 
action,  were  attributed  entirely  to  nervous  influence;  but  the 
observations  of  several  writers,  and  particularly  of  Gaskell 
in  this  country,  and  of  Engelmann  in  Germany,  have  led  to 
the  adoption  of  the  view  that  both  the  rhythm  and  the  co- 

1  Ludwig  and  Cyon,  Ludwig's  Arbeiten,  vom  Jahre  1866,  p.  128. 

2  Brunton  and  Fayrer,  Proc.  Roy.  Soc.,  1874,  vol.  xxii.,  p.  125,  and  Proc. 
Roy.  Soc.,  1876,  vol.  xxv.,  p.  72. 

"According  to  Rollett  (Hermann's  Handbuch  der  Physiologic,  vol.  iv., 
p.  152),  it  was  known  to  Meibomius  in  1668  and  to  Johannes  Miiller  in  1835. 

4  Haller,  Elementa  Physiologica,  1757,  torn.  i..  pp.  410  and  399,  and 
Memoir es  sur  la  Nature  Sensible  et  Irritable  des  Parties  du  Corps  Animal, 
1756,  torn,  iv.,  p.  4. 

8  Senac,  Traite  dc  la  Structure  du  Cccur,  etc.,  second  edition,  Paris, 
1783,  torn,  ii.,  pp.  37  and  38. 

"Colin,  Compt.  rend.,  1862,  torn.  55,  p.  495. 


HEART    OF    THE    FROG  1 9 

ordination  are  characteristics  of  the  muscle,  and  that  the 
nerves  of  the  heart  have  little  or  nothing  to  do  either  with  its 
independent  pulsation  or  with  the  regular  sequence  in  which 
the  action  of  the  auricle  follows  that  of  the  ventricle. 

Heart  of  the  Frog. — The  heart  of  the  frog  being  simpler 
in    structure    than    the    mammalian   heart,    and    more    easily 

L«ft  auricle  and  pulmonary  veins  YL.     ,.,    superior  vena  oav*  and  vagi  nerve.. 

VBIIOUS  sinus  and  Kemak's  ganglion. 


Inferior  vena  cava. 

X      .1      L  I    1      I 

Bidder's  ganglia 


FIG.   15.     Diagram   of   the    frog's   heart. 

studied,  has  been  used  to  a  great  extent  for  the  purpose  of 
discovering  the  causation  of  the  cardiac  movements.  It  con- 
sists of  the  venous  sinus,  two  auricles,  one  ventricle  and  the 
aortic  bulb.  The  vagi  nerves  pass  to  the  junction  of  the  ven- 
ous sinus  and  auricle,  and  here  form  a  plexus  or  ganglion 


ive  contraction  of  the  cavities  in  the  frog's 


known  as  Remak's.  From  this  two  nerves  pass  do\vn  the 
auricular  septum  to  the  base  of  the  ventricle,  where  they  end 
in  two  ganglia  usually  called  Bidder's  ganglia  (Fig.  15). 
The  origination  of  rhythmic  impulses,  their  conduction  in  the 


20 


THERAPEUTICS    OF    THE    CIRCULATION 


FIG.  17.  a,  diagram  of  frog's  heart  ligatured  at  the  junction  of  the  venous  sinus 
with  the  auricles.  The  venae  cavae  and  sinus  are  represented  with  a  crenated  out- 
line resembling  the  tracing  which  their  beats  might  give  if  recorded  on  a  revolving 
cylinder.  The  auricle  and  ventricle  being  motionless  would  only  trace  a  straight  line 
if  connected  with  a  recording  apparatus.  Their  outline  is  therefore  represented  by 
a  straight  line,  b,  diagram  of  a  frog's  heart  in  which  sections  have  been  made  at 
the  junction  of  the  sinus  with  the  auricles,  and  at  the  auriculo-ventricular  groove. 
The  sinus  and  ventricles  pulsate,  whilst  the  auricles  remain  motionless.  The  beats 
of  the  ventricle  should  have  been  represented  as  slower  than  those  of  the  auricle,  as 
in  /,  Fig.  1 8.  c,  the  same  as  b,  but  with  the  parts  of  the  heart  separated  by  ligature 
instead  of  section. 


FIG.  18.  d,  diagram  of  heart  with  ligature  round  the  venous  sinus,  e,  diagram 
of  heart  with  ligature  round  middle  of  auricles.  /,  diagram  of  heart  with  ligature 
in  the  auriculo-ventricular  groove.  The  pulsations  of  the  ventricle  are  much  slower 
than  those  of  the  auricle  and  venous  sinus.  This  is  indicated  by  the  larger  dentation 
of  the  outline  of  the  ventricle. 


FIG.  19.  Author's  diagram  of  the  hypothetical  nervous  apparatus  in  the  heart. 
M,  motor  ganglion.  I,  inhibitory  ganglion.  Q,  quickening  ganglion.  O,  inhibitory 
fibers;  and  S,  quickening  fibers  from  the  medulla.  A,  A',  B  and  C,  intermediate 
apparatus.  E,  fibers  passing  from  the  motor  ganglia  E,  to  the  muscular  substance  F. 
For  simplicity's  sake,  only  one  set  of  motor  ganglia  has  been  represented,  but  other 
similar  ones  are  to  be  supposed  to  be  present  in  other  parts  of  the  heart,  and  so 
connected  with  this  set  that  they  all  work  in  unison.  It  must  be  remembered  that 
this  diagram  is  purely  hypothetical;  but  if  this  be  carefully  borne  in  mind,  the  sketch 
will  be  found  of  service  in  remembering  and  comparing  the  action  of  different  poisons 
on  the  heart.  Lauder  Brunton,  Brit.  Med.  Jo-urn.,  Dec.  1871,  Collected  Papers, 
p.  311. 


EXPERIMENTS  OF  STANNIUS  21 

heart  and  their  regulation  were  regarded  as  due  to  the  nerves. 
The  experiments  of  Stannius  on  the  effects  of  ligature  or  sec- 
tion of  various  parts  of  the  heart  seemed  to  show  that  the 
nerves  of  the  venous  sinus  and  ventricle  were  chiefly  motor, 
and  those  of  the  auricle  inhibitory  (Figs.  17  and  18). 


FIG.  20.  Author's  instrument  for  showing  the  action  of  heat  and  cold  and  of 
poisons  on  the  frog's  heart.  It  consists  of  a  piece  of  tin  plate  or  glass  three  or 
four  inches  long  and  two  or  three  wide,  at  one  end  of  which  an  ordinary  cork  cut 
square  is  fastened  with  sealing-wax  in  such  a  manner  that  it  projects  half  an  inch  or 
more  beyond  the  edge  of  the  plate.  This  serves  as  a  support  to  a  little  wooden 
lever  about  three  inches  long,,  a  quarter  of  an  inch  broad,  and  one-eighth  of  an  inch 
thick.  A  pin  is  passed  through  a  hole  in  the  center  of  this  lever,  and  runs  into  the 
cork,  so  that  the  lever  swings  freely  about  upon  it  as  on  a  pivot.  The  easiest  way 
of  making  a  hole  of  the  proper  size  is  simply  to  heat  the  pin  red  hot,  and  then  to 
burn  a  hole  in  the  lever  with  it.  To  prevent  the  lever  from  sliding  along  the  pin, 
a  minute  piece  of  cardboard  is  put  at  each  side  of  it,  and  oiled  to  prevent  friction. 
A  long,  fine  bonnet-straw,  or  section  of  one,  is  then  fastened  by  sealing-wax  to  one 
end  of  the  lever,  and  to  the  other  end  of  the  straw  a  round  piece  of  white  paper,  cut 
to  the  size  of  a  shilling  or  half-crown,  according  to  convenience,  is  also  fixed  by  a 
drop  of  sealing-wax.  The  pin,  which  acts  as  a  pivot,  should  be  just  sufficiently  beyond 
the  edge  of  the  plate  to  allow  the  lever  to  move  freely,  and  the  lever  itself  should 
lie  flat  upon  the  plate.  Its.  weight,  too,  increased  as  it  is  by  the  straw  and  paper 
flag,  would  now  be  too  great  for  the  heart  to  lift,  and  so  it  must  be  counterpoised. 
This  is  readily  done  by  clasping  a  pair  of  bulldog  forceps  on  the  other  end.  By 
altering  the  position  of  the  forceps  the  weight  of  the  lever  can  be  regulated  with 
great  nicety.  If  the  forceps  are  drawn  back  as  at  c,  the  flag  is  more  than  counter- 
balanced, and  does  not  rest  on  the  heart  at  all;  while  the  position  a  brings  the  center 
of  gravity  of  the  forceps  in  front  of  the  pivot,  and  increases  the  pressure  of  the 
lever  on  the  heart.  The  isolated  frog's  heart  is  laid  under  the  lever  near  the  pivot, 
and  as  it  beats  the  lever  oscillates  upwards  and  downwards.  When  used  for  de- 
monstrating the  action  of  poisons  the  wooden  lever  should  be  covered  with  sealing- 
wax,  so  as  to  allow  every  particle  of  the  poison  to  be  washed  off  it,  and  thus  prevent 
any  portion  from  being  left  behind  and  interfering  with  a  future  experiment.  By 
attaching  a  small  point  to  the  end  of  the  straw  in  place  of  the  paper  flag,  tracings 
may  be  taken  upon  smoked  paper  fixed  on  a  revolving  cylinder.  The  fact  that  heat 
accelerates  and  cold  retards  the  pulsations  of  the  heart  is  one  of  fundamental  im- 
portance, both  in  regard  to  a  right  understanding  of  the  quick  pulse,  which  is  one 
of  the  most  prominent  symptoms  of  fever,  and  to  a  correct  knowledge  of  the  proper 
treatment  to  apply  when  the  heart's  action  is  failing. 

It  may  be  shown  with  the  apparatus  just  described  by  placing  a  piece  of  ice  under 
the  tin  plate.  The  pulsations  will  become  slower  and  slower,  and  if  the  room  be 
not  too  warm  the  heart  may  stand  completely  still  in  diastole.  On  removing  the  ice 
from  the  plate  the  pulsations  of  the  heart  become  quicker.  If  a  spirit-lamp  be  now 
held  at  some  distance  below  it  the  heart  beats  quicker  and  quicker  as  the  heat 
increases,  until  at  last  it  stands  still  in  heat-tetanus.  On  again  cooling  it  by  the  ice, 
its  pulsations  recommence. 


22 


THERAPEUTICS    OF    THE    CIRCULATION 


Investigation  of  the  Movements  of  the  Frog's  Heart.— 

The  movements  of  the  frog's  heart  may  be  investigated  either 
by  a  simple  lever  laid  upon  the  ventricle  (Fig.  20),  or  by  levers 
laid  on  the  sinus  auricle  and  ventricle  or  by  connecting  the 
ventricle  with  a  small  manometer  (Figs.  21,  22,  31  and  170). 


FIG.  21.  Dr.  H.  P.  Bowditch's  apparatus  for  experiments  on  the  heart  of  the 
frog.  A  is  the  frog's  heart.  B  is  a  cannula  tied  into  the  vena  cava,  and  B'  one 
into  the  aortic  bulb.  C,  C'  and  C"  are  three  glass  stopcocks.  By  C  fresh  serum 
is  supplied,  by  C'  old  serum  is  let  out,  and  C"  allows  the  communication  between  the 
bent  tube  B  C'  B'  and  the  manometer  M  to  be  opened  or  shut  at  will.  D  is  a  glass 
plate,  through  which  the  bent  tube  B  C'  B'  passes.  £  is  a  rod  ending  in  a  ring  into 
which  D  is  fitted.  F  is  a  nut  by  which  the  whole  apparatus  can  be  moved  up  and 
down  on  the  stand  G.  H  is  a  T-tube.  /  and  /'  are  two  clips  to  stop  the  flow  of 
serum  from  K  or  K'.  K  and  K'  are  two  fountain-bottles  for  supplying  serum  to  the 
heart.  K  contains  pure,  and  K'  poisoned  serum.  L  and  L'  are  bent  tubes  which 
convey  the  serum  out  of  K  and  K'.  M  is  a  small  manometer.  N  is  the  pen  or 
point  which  swims  on  the  mercury.  The  horizontal  part  is  made  of  glass;  the 
vertical  rod  of  esparto  grass,  with  a  small  piece  of  sealing-wax  at  its  lower  end. 
The  tracing  may  be  made  with  ink,  or  with  a  dry  point  on  smoked  paper.  P  is  a 
small  weight  which  hangs  by  a  piece  of  unspun  silk  from  a  bent  wire,  and  keeps 
the  pen  resting  on  the  paper.  Q  is  the  revolving  cylinder.  R  is  the  clockwork, 
which  is  provided  with  one  of  Foucault's  regulators.  5"  is  a  table,  which  can  be 
raised  or  lowered  at  pleasure,  and  fixed  at  any  height  by  the  screw  T.  V  is  an  india- 
rubber  tube,  through  which  the  serum  is  emptied  from  X.  X  is  a  graduated  tube, 
into  which  the  serum  is  allowed  to  pass  after  it  has  circulated  some  time.  Y  is  an 
india-rubber  tube,  which  is  generally  closed  by  a  clip,  but  is  opened  when  the 
apparatus  is  to  be  filled,  or  when  we  wish  to  let  down  the  mercury  to  zero,  in  order 
to  draw  an  abscissa.  W  is  a  glass  vessel,  which  fits  tightly  to  the  under  side  of  D, 
and  protects  the  heart  from  external  irritation.  Into  the  two  holes  seen  in  D 
tubes  may  be  fitted  air-tight,  and  the  heart  made  to  pulsate  in  an  atmosphere  of  any 
sort  of  gas. 


MOVEMENTS    OF    THE    FROCKS    HEART 


According-  to  Gaskell,1  who  supports  his  opinion  by  numer- 
ous beautiful  experiments,  the  beat  of  the  heart  in  cold-blooded 
vertebrates  depends  upon  the  rhythmical  power  of  the  inuscu- 


Klask  containing 

nutrient  fluid  - 


Valve  opening 

towards  heart 


Valve  with  slit. 


Recording  cylinder 


Manometer. 


Heart  - 
Valve  opening"! 
from  heart  / 

FIG.  22.  Diagram  of  Williams's  apparatus  for  investigating  the  action  of  drugs  on 
the  heart  of  the  frog.  It  consists  of  a  Y-shaped  cannula  whose  stem  is  divided 
by  a  longitudinal  septum  into  two  halves,  each  of  which  is  continuous  with  the  fork 
on  its  own  side.  The  stem  is  inserted  through  the  aorta  into  the  ventricle  of  the 
heart,  which  is  kept  moist  by  being  dipped  in  a  vessel  containing  serum  or  a  dilute 
saline  solution.  One  fork  of  the  Y  is  connected  with  a  flask  containing  blood-serum 
or  other  nutritive  fluid,  and  the  other  with  a  manometer.  By  means  of  valves  these 
fluids  are  made  to  flow  only  in  one  direction.  These  valves  consist  of  a  piece  of 
glass  tubing  with  a  slit  on  one  side;  over  this  slit  is  loosely  tied  a  piece  of  thin 
membrane  (gold-beater's  skin)  which  covers  about  three-quarters  of  the  circumfer- 
ence of  the  tube.  This  membrane  allows  fluid  to  pass  readily  out  of  the  tube  from 
within  outwards,  but  not  from  without  inwards,  any  external  pressure  causing  the 
membrane  to  become  tightly  applied  to  the  slit  and  to  close  it. 

A  very  useful  form  of  apparatus  for  investigating  the  action  of  drugs  on  the 
frog's  heart  and  on  the  effect  of  the  vagus  upon  it  is  made  by  combining  the  valves 
in  Williams's  apparatus  with  the  apparatus  of  Ludwig  and  Coats. 


FIG.  23.  Perfusion  cannula  with  anterior  part  removed  so  as  to  show  the  septum. 
a,  tube  for  the  introduction  of  fluid  into  the  heart,  b,  tube  for  allowing  escape  of 
fluid,  c,  tube  for  connecting  with  manometer,  d,  end  for  introduction  into  the 
heart. 

lar  tissue  in  the  large  veins  and  sinus  being  greater  than  the 
rhythmical  power  of  the  other  parts  of  the  heart.  He  thinks 
that  in  all  cases  the  greater  or  less  rhythmicity  of  any  part  of 

1  Gaskell,  Journ.  of  Physiology,  1883,  vol.  iv.,  p.  80. 


24  THERAPEUTICS    OF    THE    CIRCULATION 

the  heart  depends  upon  the  nature  of  the  muscular  fiber  of 
which  that  part  is  composed,  and  not  upon  the  presence  or 
absence  of  ganglion  cells. 


k 


FIG.    24.     View    of   the    auricular   septum   in    the    frog    (seen    from    the   left    side), 
he   nerves    are    stained    with    osmic    acid,     n    is   the    posterior,    and    n'    the    anterior 


cardiac  nerve;  t  is  a  horizontal  portion  of  the  latter  nerve;  b  is  the  posterior,  and 
b'  the  anterior  auriculo-ventricular  ganglion;  m  is  a  projecting  muscular  fold.  [This 
figure  is  taken  by  the  kind  permission  of  my  friend,  M.  Ranvier,  from  his  Lefons 
d'Anatomie  generate,  Annee  1877-78,  "Appareils  nerveux  terminaux,"  t.  6,  p.  79.] 


FIG.   25.     Part  of  the  posterior  cardiac  nerve,   highly  magnified,   showing  the   ganglia. 
[Ranvier,   Lefons  d'Anatomie   generals,   Annee   1877-78,   p.    106.] 

Now  there  can  be  no  doubt  that  living  protoplasm  can  be 
induced  to  contract  rhythmically  by  a  constant  stimulus  when- 
ever such  contraction  is  capable  of  observation.  Undifferen- 


EMBRYONIC    HEART 


tiated  protoplasm  has  the  power  both  of 
contracting  under  their  influence.  As 
differentiation  occurs  in  muscle  and 
nerve,  the  contractile  power  becomes 
increased,  and  excitability  diminished 
in  muscle;  whilst  in  nerves  excitability 
becomes  greatly  increased  and  contrac- 
tile power  so  greatly  lessened  as  to  be 
practically  abolished. 

In  the  embryo  the  heart  pulsates 
rhythmically  before  any  nerves  make 
their  appearance,  and  according  to  Gas- 
kell,  as  the  simple  tube  of  the  em- 
bryonic heart  becomes  developed  the 
specialized  muscular  walls  acquire  a 
power  of  more  rapid  contraction.  But 
this  nearer  approach  to  striated  muscle 
is  made  at  the  expense  of  the  original 
rhythmical  power,  so  that  finally  the 
muscular  tissue  of  the  heart  becomes 
differentiated  into  portions  of  different 
kinds  of  varying  rhythmical  power, 
according  to  the  amount  of  deviation 
from  the  original  embryonic  muscle. 
The  parts  that  remain  least  altered  are 
(i)  the  large  veins,  (2)  the  venous 
sinus,  (3)  the  junction  of  the  sinus 
and  auricle,  (4)  the  circularly 
arranged  fibers  of  the  auriculo- ven- 
tricular groove,  and  lastly,  (5)  the  bul- 
bus  arteriosus. 

The  sequence  of  contraction  of  the 
different  parts  of  the  heart  is  also, 
according  to  Gaskell,  no  more  depend- 
ent upon  the  presence  of  ganglion  cells 
than  the  heart-beat  itself,  but  is  due  to 


conducting  stimuli  and 


A.K. 

FIG.  26.  Spiral  ganglion 
cell  from  the  pneumogastric 
of  the  frog.  This  figure  is 
not  taken  from  the  cells  in 
the  cardiac  nerves,  as  in 
them  the  connection  between 
the  spiral  and  straight  fibers 
has  not  been  clearly  made 
out,  but  it  is  probable  that 
these  cells  have  a  structure 
similar  to  the  one  figured 
(Ranvier,  op.  cit.,  pp.  114- 
120).  a  is  the  cell-body,  n 
the  nucleus,  r  the  nucleolus, 
d  nucleus  of  the  capsule,  / 
the  straight  fiber,  g  Henle's 
sheath,  sp  spiral  fiber,  g'  its 
gaine,  n'  nucleus  of  Henle's 
sheath.  [Ranvier,  Lefons 
d'Anatomie  generate,  Annee 
1877-78,  p.  114-] 


26 


THERAPEUTICS    OF    THE    CIRCULATION 


a  peristaltic  wave  of  contraction  starting  from  that  part  of  the 
heart  where  the  tissue  is  most  automatically  rhythmical,  travel- 
ling most  quickly  over  those  parts  which  approach  most  nearly 
in  properties  to  striated  muscle,  and  more  slowly  over  those 
parts  which  retain  a  more  embryonic  character,  viz.,  the  auric- 
ulo-ventricular  ring  and  the  bulbus  arteriosus.  According  to 
Gaskell,  the  cardiac  muscle  under  certain  circumstances  will 
act  like  a  nerve,  conveying  a  stimulus  to  other  parts  of  the 
heart  without  contracting  itself.  His  experiments,  I  think, 
clearly  show  that  the  rhythmical  action  and  normal  sequence 
of  contraction  in  the  cavities  can  be  maintained  by  the  more 
or  less  differentiated  cardiac  muscle  without  ganglia  or  nerves. 
But  although  this  may  occur  under  certain  circumstances, 
more  especially  when  abnormal  stimuli  are  applied,  the  ques- 
tions arise — 

(i)  Is  the  contraction  of  the  heart,  under  normal  condi- 
tions, due  entirely  to  its  muscular  tissue?  (2)  Are  the  gan- 
glia it  contains  entirely  superfluous, 
except  in  the  way  of  restraining  its 
beats,  or  maintaining  the  nutrition 
of  the  cardiac  muscle? 

Now,  there  can  be  no  doubt  that 
the  heart  of  the  embryo  pulsates 
rhythmically  before  any  nerves 
Amoeba  quickly  chang-  make  their  appearance.  The  vesi- 
cle in  an  amoeba  contracts  (Fig. 
27),  although  there  are  no  nerves, 
and  numerous  observations  go  to  show  that  living  protoplasm 
can  be  induced  to  contract  by  a  constant  stimulus  wherever 
such  contraction  is  capable  of  observation.  But  the  question 
is  not  whether  the  heart  can  contract  rhythmically  without 
nervous  action,  but  does  it  do  this  under  ordinary  circum- 
stances ? 

Comparison  between  the  Heart  and  a  Medusa. — Experi- 
ments of  Romanes. — The  nervous  and  muscular  structures  of 


FIG.  27. 

ing  its  form,     n  is  the  nucleus,  and 
f   is   an    ingested    diatom. 


COMPARISON    BETWEEN    HEART    AND    MEDUSA 


Polypite 


Tentacles.        IJell.. 
Lithocyst  and 
ganglion. 

Lithocyst  and 

ganglion 

Bell.  Tentacles.... 


Polypite. 


Fie.  28.     Medusa     (Sarsia),     natural 
size. 


FIG.  29.     Medusa     (Sarsia),     natural 
size    (inverted). 


, 


FIG.  30.  Ventricle  of 
frog's  heart  with  Bid- 
der's ganglia. 


the  heart  are  very  intimately  related,  and  it  is  perhaps  easier 
to  observe  the  relationship  between  protoplasm  and  nerves  in 
the  medusae,  or  jelly-fish,  where  they  can  be  more  easily  sepa- 
rated. A  number  of  observations 
were  made  upon  medusse  by  Romanes.1 
A  medusa  consists  of  a  bell-shaped 
piece  of  contractile  protoplasm,  from 
the  center  of  which  a  polyp  descends, 
and  round  the  margin  of  the  bell  is  a 
nervous  gangliated  chain  and  a  fringe  of  mobile  tentacles. 
(Fig.  28.)  For  the  purpose  of  description,  we  may  put  the 
polyp,  for  the  present,  out  of  account,  and  if  we  invert  the  bell 
(Fig.  29)  we  find  that  it  bears  a  very  close  resemblance  to  the 
ventricle  of  the  frog,  which,  like  it,  consists  of  a  contractile 
portion  with  ganglia  at  its  margin.  (Fig.  30.)  When  the 
complete  medusa  is  placed  in  sea-water,  the  bell  contracts  rhyth- 
mically,'just  like  a  heart.  When  the  nerves  are  removed  by 
cutting  off  the  marginal  strip  which  contains  them,  the  bell 
ceases  to  contract;  but  it  will  recommence  if  a  constant  stimu- 
lus, either  chemical  or  electrical,  be  applied  to  it  by  the  addition 
of  acid  to  the  water  in  which  it  floats,  by  alcohol  or  glycerine 
dropped  on  its  surface,  or  by  the  passage  of  a  constant  or 
interrupted  electrical  current  through  it.2  In  this  respect  it 
completely  resembles  the  apex  of  the  frog's  heart,  which  ceases 

1  Romanes,  Phil.  Trans.,  1877,  for  1876,  vol.  clxvi.,  p.  269;  for  1878,  vol. 
clxvii.,  p.  659;  for  1881,  vol.  clxxi.,  p.  161.    Proc.  Roy.  Soc.,  1876,  p.  143,  etc. 

2  Romanes,    op.    cit.,   and   Jelly-fish,   Star-fish   and   Sea-urchins,   p.    175 
et  seq.;  vol.  iv.  of  International  Scientific  Series   (Kegan  Paul,  Trench  & 
Co.,  London,  1885). 


28 


THERAPEUTICS    OF    THE    CIRCULATION 


to  beat  when  the  ganglia  at  its  base  are  removed,  but  which 
will  again  beat  rhythmically  if  a  constant  stimulus  be  applied 


FIG.  31.  Diagram  to  show 
the  difference  in  the  mode  of 
experimenting  with  the  heart 
and  with  the  apex  alone.  In 
a  the  apex  alone  is  attached 
to  the  cannula.  In  b  the  heart, 
consisting  of  ventricle  and 
auricles,  or  of  the  venous  sinus 
also,  is  attached  to  the  cannula. 


FIG.  32.  Shows  the  increasing  contrac- 
tions of  the  tissue  of  the  medusa  when 
stimulated  by  repeated  weak  induction 
shocks  of  the  same  intensity.  The  first 
two  shocks  had  no  apparent  effect,  and  the 
first  feeble  contraction  seen  in  the  figure 
was  caused  by  the  third  shock.  (From  a 
paper  by  Romanes  in  Phil.  Trans.) 


to  it  by  pressure  of  fluid  in  its  inside,  by  the  application  of 
stimuli  such  as  dilute  acids  or  alkalies,  ammonia,  strong  saline 


FIG.   33.     Increasing   contractions  of   the  ventricle  of  the   frog's  heart   with  successive 
stimuli.      (After   Bowditch,   Ludwig's  Arbeiten.)    Cf.   Fig.    57. 

solution,  alcohol,  etc.,  or  by  the  passage  of  a  constant  current 
through  it.     Moreover,  when  a  stimulus  is  first  applied  it  may 


Strip  of  contractile  tissue  with 
fringe  of  tentacles 


FIG.  34.     Diagram  of  a  medusa   (Tiaropsis),  about  one-third  natural  size,  with  a  strip 
of  contractile  tissue  cut  from  the  bell,  but  left  attached  at  one  end. 


PROPAGATION    OF    STIMULI    IN    MEDUSA  29 

not  appear  to  act,  but  when  applied  several  times  the  contrac- 
tions it  induces  are  stronger  and  stronger  up  to  a  certain  maxi- 
mum (Fig.  32),  so  as  to  produce  the  appearance  of  a  staircase 
— a  phenomenon  which  was  also  observed  by  Bowditch1  in  the 
case  of  the  heart.  (Fig.  33.)  When  a  strip  of  medusa  con- 
taining the  ganglia  is  detached  only  at  one  end  from  the  animal 
and  is  left  attached  at  the  other,  irritation  of  the  strip  will 
cause  a  wave  to  pass  along,  which  is  of  two  kinds.  The  first 
is  that  of  contraction  in  the  protoplasm,  and  the  other  is  a  ner- 
vous stimulus,  which  makes  itself  evident  by  the  movements  of 
the  tentacles.  (Fig.  34.)  These  waves  generally  pass  to- 
gether, the  nervous  wave  being  usually  a  little  in  front  of  the 
contraction  wave;  but  it  may  also  occur,  as  is  shown  by  the 
movements  of  the  tentacles,  without  any  contraction-wave  in 
the  protoplasm  of  the  strip.  This  nervous  wave  is  more  easily 
excited  than  the  contraction-wave,  so  that  it  may  be  started  by 
stimuli  which  are  too  slight  to  affect  the  contractile  substance, 
the  ganglia  apparently  being  more  sensitive  than  the  proto- 
plasm. Apparently,  also,  for  this  reason,  when  the  nervous 
wave  reaches  the  bell  it  will  cause  it  to  contract  if  there  be 
ganglia  still  present  in  the  bell ;  but  if  these  have  been  removed, 
the  nervous  wave  has  not  the  power  of  stimulating  the  proto- 
plasm in  the  bell,  which,  consequently,  remains  motionless. 

The  passage  of  stimuli  along  the  strip  may  be  hindered  or 
prevented  by  compressing  it,  by  partially  dividing  it  so  as  to 
narrow  it,  or  by  straining  it  so  as  to  injure  it,  or  by  poisons, 
and  as  one  would  expect-  from  different  kinds  of  injury,  some- 
times the  contraction  wave  is  blocked  first  and  sometimes  the 
nervous  wave. 

The  effects  of  poisons  on  medusae  were  localized  by  Romanes 
(Phil.  Trans,  for  1876  and  1877)  in  two  ways.  One  way  was 
to  divide  the  medusa  almost  into  two  halves,  connected  only  by 
a  narrow  strip  of  tissue.  These  halves  were  plunged  into 
two  beakers  filled  with  sea-water,  pure  in  one  and  poisoned  in 
1  Bowditch,  Ludti'ig's  Arbeitcn,  1871,  p.  155. 


THERAPEUTICS    OF    THE    CIRCULATION 


the  other.  The  connecting  strip  rested  upon  the  edges  of  the 
beaker.  (Fig.  35.)  When  curare  was  employed  in  this  way, 
it  was  found  to  paralyze  the  motor  nerves,  while  it  left  the 
sensory  nerves  capable  of  action.  Thus,  on  nipping  the  half 
of  a  medusa  which  was  plunged  in  the  curare  solution,  it  re- 
mained absolutely  motionless,  while  the  other  half  at  once  re- 
sponded by  a  peculiar  contraction  to  the  stimulus. 

Nicotine  appeared  to  paralyze  the  ganglionic  structures  and 
not  the  nerves. 

The  rhythmical  movements  of  medusae  depend  upon  the 
ganglia:  when  these  are  all  cut  off  the 
movements  cease,  but  if  only  one  be  left 
the  movements  continue.  In  the  medusa 
divided  into  two  halves,  as  already  de- 
scribed, it  is  evident  that  if  the  ganglia 
are  removed  from  one  half,  or  one  half 
rendered  functionally  inactive  by  poison, 
that  half  will  still  continue  to  contract,  so 
long  as  it  remains  connected  with  the 
other  half,  but  will  cease  to  move  when 
it  is  completely  divided  from  the  half 
which  still  contains  ganglia.  The  effect  of  nicotine  is  such 
as  one  would  expect  if  the  poison  paralyzes  the  ganglia, 
for  it  is  found  that  when  one  half  of  a  medusa  is  steeped  in 
water  containing  nicotine,  both  halves  still  continue  to  pulsate 
rhythmically;  so  soon  as  the  connecting  band  of  tissue  is  di- 
vided, the  poisoned  half  at  once  ceases  to  move,  while  the  other 
half  continues  to  pulsate. 

The  second  way  in  which  Romanes  localized  the  action  of 
poisons  on  medusae  was  by  applying  them  to  a  strip  of  contrac- 
tile tissue.  (Fig.  36.)  He  found  that  various  poisons  ap- 
plied to  the  strip,  or  injected  into  it,  caused  a  blockage  of  con- 
tractile waves,  preceded  by  a  progressive  slowing  of  the  rate 
of  transmission  along  the  poisoned  part.  Chloroform,  ether, 
alcohol,  morphine,  strychnine  and  curare  all  have  this  effect. 


FIG.  35.  Diagram- 
matic representation  of 
the  method  of  localizing 
the  action  of  poisons  on 
medusae.  One  vessel  con- 
tains normal  sea-water; 
another  contains  poi- 
soned sea-water,  which  is 
shaded  in  order  to  dis- 
tinguish it. 


EFFECT    OF    POISONS    ON    MEDUSA  31 

When  the  block  is  only  partial,  it  may  happen  that  three 
waves  come  up  to  it  before  one  can  pass  across,  as  if  each  wave 
had  prepared  the  passage  for  the  remainder,  and  at  last  the 
third  or  fourth  overcomes  the  obstacle. 

Gaskell  has  noticed  a  similar  effect  from  compression  of  the 


FIG.  36.  Medusa  (Aurelia  aurita)  from  which  the  ganglia  have  been  removed, 
and  the  bell  cut  into  a  long  strip  with  cross  cuts  to  block  the  passage  of  contractile 
and  tentacular  waves.  The  polypite  is  at  the  other  end.  a  and  b  are  at  the  two 
ends  of  the  strip.  When  stimulation  was  applied  to  either  a  or  b,  a  tentacular  wave 
started  from  that  point  and  travelled  all  the  way  to  the  other  end.  After  Romanes, 
Phil.  Trans,  for  the  year  1877,  vol.  clxvii.,  part  ii.,  p.  719,  and  Plate  31. 

auriculo-ventricular  groove  in  the  frog's  heart,  and  the  same 
thing  is  also  observed  in  certain  cases  of  cardiac  disease  and 
from  the  action  of  cardiac  poisons.  (Fig.  37.) 

Transmission  of  Stimuli  in  the  Heart. — If  (i)  all  the 
rhythmical  power  of  the  auricles  and  ventricles  and  (2)  all 


32  THERAPEUTICS    OF    THE    CIRCULATION 

their  coordinated  action  are  dependent  only  on  the  cardiac 
muscle,  one  would  say  that  it  was  quite  unnecessary  to  have 
such  an  extraordinary  abundance  of  nerves  as  exists  in  the 
heart.  One  would  be  inclined  to  say  that  they  are  superabund- 
ant and  useless,  but  one  cannot  help  remembering  that  years 


_U_   Hi   IV   ptr 

yi       i      i     etc. 
y 

a-  o 

FIG.  37.  Diagram  to  illustrate  Gaskell's  experiment.  At  a  the  jaws  of  the  clamp 
hold  the  heart  without  compressing  it,  and  each  beat  of  the  auricle  is  succeeded  by 

one  of  the  ventricle,   as  shown  by  the  figure   i.      At  b  the  heart  is  compressed,  and 

its  rhythm  disturbed,  so  that  one  beat  of  the  ventricle  only  occurs  for  several  of 
the  auricles.  This  is  indicated  by  the  Roman  numbers,  the  upper  line  of  which  shows 
the  number  of  auricular,  and  the  lower-  of  ventricular  beats. 

ago  the  liver  was  looked  upon  as  a  totally  unimportant  organ, 
whose  only  function  it  was  to  secrete  a  little  bile.  Fuller 
knowledge  has  shown  that  instead  of  being  useless,  it  is  one 
of  the  most  important  organs  in  the  body;  and  in  all  proba- 
bility increased  knowledge  will  again  show  the  importance  of 
the  cardiac  nerves.1 

In  order  that  we  may  understand  the  object  of  these  nerves 
more  easily,  I  may  perhaps  be  allowed  to  employ  a  simple  com- 
parison. A  railway  train,  when  once  started,  usually  proceeds 
from  station  to  station  without  interference;  but  alongside  the 
rail,  or  overhead,  run  the  telegraph  wires,  and  at  any  station 
the  progress  of  the  train  may  be  stopped  by  a  message  sent  by 
the  telegraph.  You  will  notice  also  that  in  many  railways  an 
electric  bell  rings  before  the  train  actually  appears,  so  that  all 
preparations  may  be  made  for  its  arrival.  In  the  heart  the 
transmission  of  stimuli  by  the  cardiac  muscle  would  correspond 
to  the  passage  of  the  train;  the  transmission  by  the  nerves 
would  correspond  to  the  telegraph,  by  which  the  movement  of 

1The  importance  of  the  cardiac  ganglia  in  originating  the  beats  of  the 
heart  has  been  prominently  brought  forward  since  these  lectures  were 
given,  by  Dogiel  and  Archangelsky,  Pfliiger's  Archiv,  July,  1906,  vol.  cxiii., 
pp.  1-96. 


CONDUCTION    OF    STIMULI    IN    THE    HEART  33 

the  ventricle  might  either  be  stopped,  even  after  an  impulse  had 
been  sent  on  from  the  auricle,  or,  on  the  other  hand,  the  ven- 
tricle might  be  prepared  to  respond  more  quickly  to  the  stimu- 
lus passing  from  the  auricle.  The  advantage  of  such  a  prepa- 
ration is  evident  from  Romanes'  experiments,  in  which  stimuli 
did  not  always  produce  the  proper  effect  unless  they  had  been 
preceded  by  another  stimulus  which  prepared  the  protoplasm 
to  react. 

Nervous  and  Muscular  Conduction  in  the  Heart. — Act- 
ing upon  the  idea  which  I  have  tried  to  illustrate  to  you  by  the 
train  and  the  telegraph,  Dr.  Cash  and  I  endeavored  to  find  out 
whether  we  were  able,  by  stimulation  of  the  venous  sinus  or  of 
the  auricle  in  the  excised  frog's  heart,  to  produce  such  changes 
in  the  ventricular  contraction  as  one  might  expect  if  there  were 
really  two  lines  of  communication,  nervous  and  muscular, 
instead  of  muscular  alone.  The  bearing  of  this  upon  cardiac 
irregularity  is  naturally  of  the  greatest  importance. 

I  have  already  mentioned  that  there  is  a  refractory  period 
during  which  the  ventricle  does  not  appear  to  react  to  stimula- 
tion. This  was  pointed  out  by  Marey,  and  the  time  relations 
of  this  period,  as  well  as  the  electrical  changes  which  accom- 
pany it,  were  investigated  by  Sir  John  Burdon-Sanderson  and 
Mr.  Page.1 

Experiments  of  Brunton  and  Cash. — The  results  that 
Cash  and  I  obtained  agree  with  those  of  previous  observers, 
and  I  show  you  here  some  tracings  to  illustrate  this  point.  In 
regard  to  these  tracings,  as  well  as  to  all  the  others  contained 
in  the  paper  from  which  it  is  taken,  I  may  say  that  the  investi- 
gation extended  over  nearly  three  years,  that  the  number  of 
tracings  was  enormous,  and  that  our  conclusions  were  founded 
upon  very  numerous  observations,  and  not  merely  upon  the 
small  pieces  which  are  printed  in  the  paper,  which  were  cut 
down  to  the  lowest  possible  minimum,  on  account  of  the  ex- 
pense of  printing.  These  illustrations  are  merely  to  show  the 

1  Burdon-Sanderson  and  Page,  Roy.  Soc.  Proc.,  1878,  p.  410;  1880,  p.  373. 

4 


34  THERAPEUTICS    OF    THE    CIRCULATION 

points  which  we  made  out,  but  are  not  to  be  regarded  as  being 
the  basis  upon  which  our  conclusions  were  founded.1  I  wish 
to  lay  particular  stress  upon  this  point,  lest  the  small  number 
of  tracings  printed  in  the  paper  should  lead  other  workers  on 
this  subject  to  reject  our  conclusions  as  being  founded  on 
insufficient  data,  when  in  fact  the  number  of  experiments  was 
very  large. 

Irritation  of  the  ventricle  at  the  commencement  of  systole 
nearly  up  to  its  maximum,  i.  e.,  during  the  refractory  period, 
has  no1  effect  at  all.  (Fig.  38,  a,  &.)  Stimulation  from  the 
maximum  of  systole  to  its  end  causes  a  reduplication  of  the 
systole  (Fig.  39),  and  in  the  diastole  it  does  the  same  almost 
immediately.  (Fig.  40.) 

When  the  auricle  is  stimulated,  the  stimulation  may  cause 
a  second  auricular  beat  immediately  after  the  first.  (Fig.  41.) 
This  second  beat,  in  place  of  being  succeeded  by  a  ventricular 
pulse,  prevents  the  next  ventricular  beat  from  following  in 
order,  just  as  two  trains  may  be  started  in  almost  immediate 
succession  from  one  station,  and  a  telegraphic  message  may  be 
sent  on  at  the  same  time  that  the  second  train  is  not  to  be 
allowed  to  pass  the  next  station. 

When  the  venous  sinus  was  stimulated  it  produced  redupli- 
cation of  the  auricular  beat,  but  absence  of  the  ventricular  beat 
which  should  have  succeeded  it,  in  much  the  same  way.  (Fig. 

42.) 

Conduction  of  Impulses  both  by  Muscle  and  Nerves. — 

These  experiments,  which  were  not  only  very  numerous,  but 
very  varied,  seemed  to  us  to  show  that,  just  as  in  a  medusa, 
there  are  in  the  heart  two  distinct  channels,  the  nervous  as  well 
as  the  muscular,  by  which  stimuli  are  conducted  from  one  part 

1  Brunton  and  Cash,  "  On  electrical  stimulation  of  the  Frog's  Heart,  and 
its  modification  by  cold,  heat,  and  the  action  of  drugs,"  Roy.  Soc.  Proc., 
1881,  vol.  xxxii.,  No.  214,  and  1883,  vol.  35,  No.  227,  p.  455.  The  instru- 
ment with  which  the  observations  were  made  was  devised  by  Dr.  Cash, 
and  described  by  him,  Journ.  of  Physiology,  iv.,  1883,  p.  128. 


BRUNTON  AND  CASH  S  EXPERIMENTS 


35 


FIG.  38.  Tracing  showing  the  effect  of  electrical  stimulation  upon  the  ventricle  of 
the  frog's  heart.  The  upper  line  shows  the  ventricular  contraction,  the  lower  one  the 
auricular  contraction,  and  the  middle  line  the  time  of  application  of  the  electrical 
stimulus.  The  depression  shows  the  time  of  breaking,  and  the  ascent  the  time  of 
again  making  the  current.  In  most  of  these  tracings  only  the  break  is  effective  as  a 
stimulus.  The  arrow  shows  the  direction  in  which  the  tracing  is  to  be  read.  The 
dotted  line  shows  more  exactly  the  exact  time  in  regard  to  the  systole  at  which  the 
stimulus  was  applied.  In  both  o  and  b  the  stimulus  falls  within  the  refractory  period, 
and  produces  no  effect.  In  this  and  the  following  tracings  the  movements  of  the 
ventricle  and  auricle  were  registered  by  levers  resting  on  them. 


FIG.  39.  Effect  of  electrical  stimulation  of  the 
frog's  ventricle  after  the  refractory  period  has 
passed.  It  shows  different  forms  of  reduplication; 
also,  that  the  auricular  systole  following  the  stimu- 
lation is  nearly  coincident  with,  or  even  a  little 
later  than,  the  ventricular  systole,  instead  of  pre- 
ceding it  in  the  usual  way. 


FIG.  40.  Shows  redupli- 
cation of  the  beat  of  the 
ventricle  from  stimulation 
applied  to  it  during  the 
diastole. 


of  the  heart  to  another,  and  that  the  nervous  conduction  may 
interfere  with  the  muscular  conduction.1 


explanation  is  in  accord  with  the  conducting  function  of  the 
bundles  of  His,  or  the  fibers  of  Purkinje,  which  may  be  regarded  as  neuro- 
muscular.  Since  these  lectures  were  given,  the  conducting  function  of  the 
muscular  bundle  described  by  Stanley  Kent  in  1892  (Proc.  Physiol.  Soc., 
Nov.,  1892),  and  by  William  His,  junior,  in  1893,  which  connects  the 
auricles  and  ventricles,  has  attracted  much  attention,  and  the  neuro- 
muscular  fibers  described  by  Purkinje  have  also  come  again  more  into 
notice.  The  bundle  of  His  is  thus  described  by  him:  "The  bundle  springs 
from  the  posterior  wall  of  the  right  auricle,  near  the  auricular  septum,  in 


THERAPEUTICS    OF    THE    CIRCULATION 


FIG.  41.  Shows  effect  of  stimulation  of  the  auricle  on  the  beats  of  the  auricle  itself 
and  of  the  ventricle.  The  weaker  stimulus  in  a  produces  no  reduplication  of  the 
auricular  beat,  although  other  experiments  showed  that  it  usually  produced  a  very 
prolonged  pause.  In  the  lower  tracing  b,  stimulation  had  various  effects,  according 
to  the  time  of  the  auricular  systole  at  which  it  was  applied.  At  b  i  it  caused  redupli- 
cation of  the  auricular  beat,  with  omission  of  the  ventricular  beat;  at  2  it  only  pro- 
duces prolongation  of  diastole  in  both  auricle  and  ventricle,  and  the  third  had  no 
apparent  effect. 


FIG.  42.  Shows  the  effect  of  stimulation  of  the  venous  sinus.  It  is  much  more 
sensitive  to  stimulation  than  either  the  auricle  or  ventricle,  so  stimuli  will  produce  an 
effect  upon  it,  although  too  weak  to  act  on  either  auricle  or  ventricle.  It  causes  re- 
duplication of  the  auricular  and  omission  of  the  ventricular  beat,  like  stimulation  of 
the  auricle  at  a,  Fig.  40.  In  the  experiment  of  which  this  is  a  tracing  a  minimal 
stimulus  was  employed,  and  only  the  opening  of  the  current  was  effective.  The  open- 
ing is  indicated  by  the  sinking  of  the  continuous  line,  and  its  closing  by  the  rise. 
The  closing  shock  produced  no  effect.  The  relation  between  the  time  of  stimulation 
and  the  auricular  contraction  (lower  tracing)  and  the  ventricular  contraction  (upper 
tracing)  is  shown  by  the  dotted  lines. 


FIG.   43.       Periodic  rhythm  of  the  heart,  the  pulsations  occurring  in   groups   separated 
by  intervals  of  complete  quiescence. 


KRONECKER    AND    SCHMEY KENT    AND    HIS  37 

Another  experiment  which  is  very  striking  is  that  of 
Kronecker  and  Schmey,1  who  found  that  by  puncturing  a  point 
in  the  septum  of  the  ventricles,  at  about  the  junction  of  its 
upper  third  with  its  lower  two-thirds,  the  rhythmical  action  of 
the  heart  is  stopped  immediately,  and  little,  quivering  tremors 
are  to  be  seen  all  over  the  ventricle,  but,  while  the  fibers  are 


FIG.  44.      Tracing  of  the  pulsations  of  a  ventricle  separated  from  the  auricles  by  sec- 
tion at  the  auriculo-ventricular  groove.      After  Ranvier,  Lcfons,   1877-78. 

contracting,  the  heart,  as  a  whole,  is  quiescent.  It  is  not 
always  easy  to  hit  this  point.  My  friend,  Professor  Kron- 
ecker, tells  me  that  he  has  sometimes  struck  it  at  the  third 

the  auriculo-ventricular  sulcus,  is  attached  to  the  superior  edge  of  the 
muscle  forming  the  ventricular  septum,  and  exchanges  fibers  with  it.  It 
passes  forwards  on  the  ventricular  septum,  till  near  the  aorta  it  divides 
into  a  right  and  left  branch,  the  latter  of  which  ends  in  the  base  of  the 
aortic  cusp  of  the  mitral  valve.  (William  His,  junior,  Arbeitcn  aus  der 
medicinischen  Klinik  Zu  Leipzig  herausgegeben,  von  Dr.  H.  Curshmann, 
Leipzig,  F.  C.  Vogel,  1893,  p.  23.)  No  nerve  trunks  are  to  be  found  in 
this  bundle  (Ritzer,  quoted  by  Erlanger),  but  it  contains  nerve  fibers 
(Tawara  and  Aschdff,  Zeitsch.  f.  Physiol.,  1905,  xix.,  p.  298),  and  the 
muscle  fibers  are  very  fine  and  of  an  embryonal  character.  The  ventricular 
part  of  the  bundle  passes  as  a  finely  ramifying  system  to  the  ventricular 
wall  and  papillary  muscles,  and  consists  of  Purkinje's  fibers.  These  fibers 
consist  of  cells  which  are  only  striated  on  their  periphery,  and  may  be  re- 
garded as  only  partially  differentiated,  and  possessing  the  properties  of 
nerve  as  well  as  muscle  (Ranvier,  Legons  d' Anatomic  Generate,  Systeme 
Musculaire,  Paris,  1850,  p.  300).  They  appear  to  conduct  the  stimuli  from 
the  auricle  to  the  ventricle  in  mammalian  hearts  more  slowly  than  nerves. 
When  the  conducting  power  of  the  bundle  of  His  is  destroyed  by  clamp- 
ing it,  similar  disturbances  of  the  relation  between  the  rhythm  of  the 
auricles  and  ventricles  is  produced,  as  Gaskell  observed  in  the  frog's  heart 
(Stanley  Kent,  Journ.  of  Physiol.,  1893,  vol.  xiv.,  p.  250;  and  Erlanger, 
Journ.  of  Experimental  Medicine,  vol.  viii.,  p.  8).  Their  degeneration 
produces  heart  block  and  intermittence  of  the  pulse. 

1  Kronecker  and  Schmey,  Sits.  bcr.  d.  Akad.  d.  IViss.  zu  Berlin,  1884, 
s.  87. 


38  THERAPEUTICS    OF    THE    CIRCULATION 

attempt,  but  on  other  occasions  he  has  tried  more  than  thirty, 
and  I  think  that  when  he  showed  it  to  me  it  was  quite  fifty 
times,  but  the  difference  between  the  time  when  he  did  not 
strike  it  and  the  time  when  he  did  so  was  most  extraordinary. 
The  effect  of  the  thin  needle  penetrating  the  heart  appeared  to 
be  nil  until  he  struck  the  proper  point,  and  then  the  rhythmical 
power  was  instantly  and  completely  abolished.  The  effect  on 
the  heart  was  similar  to  that  of  puncture  of  the  nceud  vital  in 
the  fourth  ventricle  upon  respiration. 


FIG.  45.  Diagram  of  the  author's  instrument  for  ascertaining  the  competence  ot 
the  mitral  or  tricuspid  valves,  and  illustrating  the  action  of  the  musculi  papillares. 
D  is  a  section  of  the  heart,  with  the  valves  (£)  and  the  chordae  tendineae  (F).  The 
nozzle  (A)  of  an  enema  apparatus  is  taken  off  and  its  longer  end  thrust  from  the 
inside  through  the  ventricular  wall  (B),  and  is  there  kept  in  place  by  the  flange  on  the 
inside  and  a  thick  rubber  ring  (C)  on  the  outside.  On  pumping  water  gently  in,  the 
valves  (£)  will  be  seen  to  float  upon  the  surface  of  the  water,  then  to  become  firmly 
opposed  or  screwed  together,  and  only  when  the  ventricle  is  forcibly  distended  or  dis- 
torted by  unequal  pressure  on  its  sides  do  the  valves  leak.  (Lauder  Brunton,  St. 
Bartholomew's  Hospital  Reports,  1878,  vol.  xv.,  p.  283.) 

It  is  almost  impossible  to  explain  such  a  result  as  this  on 
the  idea  that  rhythmical  contractility  is  dependent  only  upon 
the  muscular  structure ;  but  one  can  quite  readily  understand  it 
on  the  other  idea,  viz.,  that  there  are  two  controlling  conditions 


VALVES    OF    THE    HEART 


39 


in  the  heart — (i)  the  nervous  and  (2)  the  muscular,  and  that 
these  may,  under  certain  circumstances,  interfere  with  each 


FIG.   46.     Heart  in  full  sys-  FIG.  47.     The  same  heart  as 

tole,    showing    the    mitral    and  in  Fig.  46,  from  another  point 

tricuspid  orifices  so  diminished  of  view, 

by  the  muscular  contraction 
that  the  valves  close  them 
easily. 

other,  and  thus  abolish  contraction  more  or  less  completely, 
and  produce  intermittence  or  irregularity  of  the  pulse. 


FIG.  48.      Heart  fully  distended,  showing  insufficiency  of  the  valves  to  close  the  mitral 
and  tricuspid  orifices. 

Valves  of  the  Heart. — All  these  experiments  have  a  bear- 
ing upon  the  rhythm  of  the  heart,  as  we  shall  afterwards  see, 


4O  THERAPEUTICS    OF    THE    CIRCULATION 

but  the  more  common  diseases  of  the  heart  are  really  those 
associated  with  imperfection  of  the  valves.  If  the  valves  were 
not  present,  the  blood,  instead  of  being  forced  steadily  onward, 
would  tend  to  regurgitate,  but  the  presence  of  the  valves  pre- 
vents this.  In  the  aorta  and  pulmonary  artery  we  have  three 
segments  which  are  simply  brought  together  like  those  of  an 
ordinary  pump,  by  the  pressure  within  the  artery  when  the 
ventricle  ceases  to  contract.  In  the  valves  which  separate  the 
auricle  from  the  ventricle,  we  require  something  more  than 
this,  because  the  valves  are  large,  and  when  the  walls  of  the 
ventricle  approximate  during  systole  the  thin  valves  would  be 
driven  back  into  the  auricle,  were  it  not  that  they  are  attached 
by  fine  cords  and  by  muscular  columns  which,  contracting  with 
the  rest  of  the  ventricle,  draw  the  valves  downwards  and  pre- 
vent them  from  being  forced  back  into  the  auricles.  (Fig. 
45.)  The  action  of  these  valves  is  aided  by  the  contraction  of 
the  muscular  fibers  around  the  auriculo-ventricular  orifices, 
which  are  greatly  lessened  in  diameter,  so  much  so  that  one 
might  say  that  even  imperfect  valves  might  close  them  (Figs. 
46  and  47)  ;  whereas  when  the  cardiac  contraction  is  feeble  the 
orifices  may  be  too  large  to  be  completely  covered,  and  thus  a 
certain  amount  of  regurgitation  may  take  place  even  though 
the  valves  themselves  are  perfectly  healthy  (Fig.  48). 


LECTURE    II 

Sounds  of  the  Heart — Double  Nature  of  the  Heart — Right  Ventricle — 
Aorta — Arteries  and  Capillaries — Vaso-motor  Nerves — Dilating  Nerves — 
Elongation  of  Muscle(?) — Rhythmical  Contraction  of  Vessels — Stimula- 
tion of  Vessels  from  without — Stimulation  of  Vessels  from  within — Effect 
of  Heat  and  Cold  on  the  Circulation — Effect  of  Heat  and  Cold  on  the 
Pulmonary  Capillaries — Schema  of  the  Circulation — Kymographs — Blood 
Pressure  in  Animals — Blood  Pressure  in  Man — Measurement  of  the  Blood 
Pressure  in  Man — Instruments  for  Measuring  the  Blood  Pressure  in  Man : 
By  Pressure  on  an  Artery ;  By  Pressure  on  a  Finger  or  Limb ;  Sphygmo- 
manometers  of  Herisson,  Waller,  Von  Basch,  Potain  and  Oliver;  Instru- 
ments of  Marey,  Mosso  and  Gaertner. 

Sounds  of  the  Heart. — The  closure  of  the  valves  in  the 
heart  occasions  sounds  which  can  be  heard  by  putting  the  ear 
to  the  chest  wall,  and  they  can  be  still  better  localized  by  the 
use  of  a  stethoscope.  When  we  do  this,  we  hear  sounds  which 
are  well  imitated  by  the  syllables  "  lub-dup,"  close  to  one  an- 
other. These  syllables  follow  one  another  quickly,  and  then 
comes  an  interval,  which  represents  the  diastole  of  the  heart. 
The  credit  of  showing  that  the  second  sound,  "  dup,"  is  caused 
by  the  closure  of  the  aortic  valves,  belongs  to  C.  J.  B.  Williams, 
and  the  committee  in  which  he,  Hale,  and  Glendinning  took 
part.1  They  showed  that  when  the  aortic  valves  were  de- 
stroyed, the  sound  disappeared.  The  causation  of  the  first 
sound,  however,  has  given  rise  to  a  great  deal  of  discussion. 
Some  authors  have  considered  it  to  be  a  valvular  sound,  and 
due  to  the  flapping  together  of  the  auriculo-ventricular  valves ; 
whilst  others,  like  Magendie,  have  thought  it  to  be  caused  by 
the  striking  of  the  apex  against  the  chest  wall,  and  yet  others 
have  looked  upon  it  as  being  a  muscular  sound,  due  to  the 
ventricular  contraction.  There  seems  to  be  little  doubt  now, 
from  the  experiments  of  Ludwig,  Dogiel,2  and  others,  that  the 

1  Sixth  Report  of  the  British  Association,  1836,  p.  265. 

2  Ludwig' 's  Arbeiten,  1878,  p.  78. 


42  THERAPEUTICS    OF    THE    CIRCULATION 

first  sound  is  chiefly  muscular,  and  brought  about  by  the  con- 
traction of  the  ventricle;  but  the  experiments  of  Ottomar 
Bayer1  in  Ludvvig's  laboratory  demonstrated  that,  apart  from 
the  muscular  sound,  a  distinct  valvular  click  could  be  obtained 
by  the  closure  of  the  auriculo-ventricular  valves  in  a  dead 
heart,  whilst  Williams  and  his  confreres  found,  in  addition, 
that  the  first  sound  was  intensified  by  allowing  the  exposed 
heart  to  beat  against  a  piece  of  board.  We  may  thus  consider 
that  there  are  three  factors  which  all  take  part  in  the  produc- 
tion of  the  first  sound,  viz.,  (i)  the  ventricular  contraction, 
(2)  the  closure  of  the  auriculo-ventricular  valves,  and  (3)  the 
impulse  of  the  apex  against  the  chest  wall. 

As  we  would  expect,  the  first  sound  is  heard  most  loudly 
over  the  apex,  which  is  the  point  of  the  chest  wall  nearest  to 
the  ventricle.  The  second  sound  is  heard  more  sharply  over 
the  aortic  valves,  which  lie  beneath  the  left  side  of  the  sternum, 
at  about  the  level  of  the  third  intercostal  space,  but  is  heard  still 
better  at  the  point  where  the  aorta  most  nearly  approaches  the 
sternum  at  its  right  edge,  and  at  the  level  of  the  second  inter- 
costal space  or  third  costal  cartilage. 

Alterations  in  the  Second  Sound. — When  we  hear  a  door 
slammed  loudly,  we  know  that  it  is  closed  quickly  in  conse- 
quence of  the  application  of  unusual  force;  and  just  as  we 
would  expect,  when  tension  is  high  in  the  aorta  the  second 
sound  is  louder  than  usual,  or  as  it  is  termed,  is  accentuated, 
and  this  accentuation  of  the  second  sound  over  the  aorta  is  one 
of  great  clinical  importance,  indicating  as  it  does,  high  arterial 
tension  or  aortic  atheroma  or  aneurism. 

Alteration  in  the  First  Sound. — The  causation  of  the  first 
sound  being  more  complex,  alterations  in  it  occur  from  a 
greater  number  of  causes.  As  it  is  to  a  great  extent  a  muscu- 
lar sound,  we  should  naturally  expect  that  weakness  of  the 
cardiac  muscle,  such  as  occurs  in  fevers,  would  lessen  the  sound, 
and  this  is  exactly  what  occurs.  In  cases  of  typhoid  fever, 
when  the  first  sound  becomes  inaudible  we  know  that  the  heart 

1  O.  Bayer,  Arch.  f.  Hcilk.,  xi.,  p.  157. 


SOUNDS    OF    THE    HEART MURMURS  43 

is  so  weak  as  to  render  the  prognosis  grave.  But  it  would 
appear  that  it  is  not  mere  muscular  strength  which  causes  the 
sound  to  become  loud  :  it  is  rather  rapidity  of  contraction ;  and 
even  a  comparatively  feeble  heart  may  have  a  loud,  clear  first 
sound  if  the  tension  in  the  aorta  is  low,  or,  in  other  words,  if 
the  resistance  it  has  to  overcome  is  small,  so  that  it  can  contract 
rapidly.  When  the  arterial  tension  is  high,  and  the  resistance 
to  be  overcome  is  consequently  great,  the  muscular  walls  of 
the  ventricle  contract  comparatively  slowly,  and  even  when 
hypertrophied  far  beyond  their  normal  size,  they  may  give  rise 
to  a  sound  weaker  and  duller  than  normal.  Of  course,  the 
rapid  contraction  not  only  gives  rise  to  a  greater  muscular 
sound,  but  it  closes  the  auriculo-ventricular  valves  more 
sharply,  and  thus  increases  also  the  valvular  part  of  the  first 
sound.  And  yet,  again,  a  heart  contracting  quickly  gives  a 
sharp,  or  as  it  is  sometimes  called,  a  slapping  impulse  to  the 
chest  wall,  while  the  more  powerfully  hypertrophied  heart,  act- 
ing on  a  greater  resistance,  gives  a  thudding  or  pushing  im- 
pulse not  likely  to  cause  so  much  resonance,  and  thus  the  sound 
will  again  be  diminished.  The  last  factor  in  the  production  of 
the  first  sound  in  the  heart  may  also  be  lessened  by  a  thick 
layer  of  lung  between  the  ventricle  and  the  chest  wall,  as  in 
emphysema,  and  the  lung  will  also  tend  to  deaden  the  sound  by 
acting  as  a  non-conductor  between  the  ventricle  and  the  ear. 

Cardiac  Murmurs. — When  the  aortic  valves  are  destroyed, 
the  sharp  "  dup  "  which  their  closure  causes  in  health  disap- 
pears, and  is  replaced  by  a  bruit  or  murmur.  You  will  most 
easily  understand  this  by  trying  to  say  "  dup  "  with  your  lips 
apart,  and  you  will  then  find  that  without  thinking  of  it  you 
reproduce  the  sounds  actually  heard  in  aortic  incompetency. 
When  it  is  slight,  the  closure  of  the  valves  is  still  heard,  but  is 
followed  by  a  whiff,  as  when  you  say  "  duff,"  and  in  aortic 
regurgitation  the  sounds  are  like  "  lub-duff."  The  same  hap- 
pens with  the  mitral  valve,  and  when  this  valve  alone  is  incom- 
petent, the  sounds  of  the  heart  are  like  "  luff-dup  "  — "  luff- 
dup."  When  both  valves  are  slightly  incompetent,  the  sounds 


44  THERAPEUTICS    OF    THE    CIRCULATION 

are  like  "  luff-duff  "— "  luff-duff  ";  and  when  both  valves  are 
very  incompetent,  a  bellows  murmur  occurs,  like  "  oho-oho." 

Double  Nature  of  the  Heart. — For  the  sake  of  simplicity, 
I  have  spoken  hitherto  of  the  heart  as  if  it  consisted  only  of 
the  left  side,  but  we  have  in  man,  as  in  other  mammals,  really 
two  hearts  joined  together  in  one,  the  right  and  the  left;  the 
right  sending  the  blood  through  the  lungs  for  the  purpose  of 
aerating  it,  and  the  left  sending  the  blood  through  the  body  in 
order  to  nourish  the  tissues.  Both  hearts  receive  the  blood 
from  the  large  veins  into  the  auricles,  which,  contracting,  send 
it  on  to  the  ventricles,  and  thence  it  is  propelled  by  the  right 
ventricle  into  the  pulmonary  artery,  and  by  the  left  ventricle 
into  the  aorta.  As  I  mentioned  before,  both  the  vena  cava 
and  the  pulmonary  veins  have  the  power  of  rhythmically  inde- 
pendent pulsation  apart  from  the  auricle,  and  the  cardiac  beat 
may  frequently  though  probably  not  always,  originate  in  them.1 

Right  Ventricle. — The  resistance  which  the  right  ventricle 
has  to  overcome  in  driving  the  blood  through  the  pulmonary 
artery  is  only  about  one-third  that  presented  by  the  aorta,  and, 
consequently,  the  right  ventricle  is  only  about  one-third  the 
strength  of  the  left.  The  tricuspid  valves,  which  separate  the 
right  ventricle  from  the  right  auricle,  are  much  more  easily 
rendered  incompetent  by  distension  of  the  ventricle  than  are 
the  mitral  valves,  and' this  tendency  to  incompetency  has  been 
regarded,  and  I  think  with  truth,  as  a  safety  valve,  preventing 
the  stoppage  of  the  right  ventricle  by  over-distension,  and 
allowing  the  blood  to  pass  back  into  the  venous  reservoirs,  of 
which  I  have  already  spoken. 

Aorta. — On  looking  at  the  aorta,  one  would  say  that  it  is 
entirely  composed  of  fibrous  tissue,  and  consequently  is  not 
likely  to  possess  any  contractile  power,  and  yet  it  would  appear 
to  have  such  a  power,  for  in  the  case  of  a  criminal  executed  at 
Wurzburg,  it  was  found  to  contract  on  the  application  of  elec- 
tricity shortly  after  death.2 

1  Vide,  p.  20. 

*  Vcrhandl.  d.  Med.  Phys.  Gescllsch.,  Wurzburg,  1854,  p.  i ;  and  Schmidt's 
Jahrb.,  vol.  Ixxxv.,  p.  12. 


VASO-MOTOR    NERVES DILATING   NERVES  45 

Arteries  and  Capillaries. — As  we  pass  down  the  arterial 
system  the  muscular  fibers  become  more  developed,  and  in  the 
arterioles  we  find  a  continuous  muscular  layer,  while  in  the 
capillaries  we  have  nothing  but  contractile  cells.  Just  as  in  the 
case  of  the  heart,  where  we  have  two  kinds  of  nerves  having 
an  opposing  action,  so  we  have  in  the  vessels  nerves  which 
cause  contraction  and  others  which  cause  dilatation.  When 
working  with  Schweigger-Seidel  in  Ludwig's  laboratory  in 
1869,  I  made  a  number  of  observations  on  the  nerves  of  the 
arterioles  and  veins,  but  these  were  not  published,  as  I  did  not 
discover  anything  new.  I  tried  in  vain  to  find  any  evidence 
of  nerve  fibers  entering  the  muscular  cells  of  the  arterioles,  but 
could  never  observe  it.  All  that  I  could  find  was  a  regular  net- 
work of  minute  nervous  fibrils  running  over  the  surface  of  the 
muscular  layer.  At  the  points  where  these  fibrils  cross  there 
are  small  thickenings  or  knots,  but  nothing  at  all  like  ganglion 
cells. 

Vaso-motor  Nerves. — Dilating  Nerves. — Elongation  of 
Muscle  (?). — The  vaso-motor  system,  as  I  have  already  said, 
has  its  chief  center  in  the  medulla  oblongata,  but  it  has  sub- 
sidiary centers  in  the  spinal  cord  itself,  and  in  the  ganglionic 
chain  of  the  sympathetic.  When  the  centers  or  nervous  trunks 
of  the  vaso-motor  nerves  are  irritated,  the  vessels  contract ;  but 
there  are  other  nerves  which  when  irritated  cause  dilatation 
instead  of  contraction,  and  this  dilatation  is  greater  than  that 
which  occurs  on  the  division  of  the  vaso-motor  fibers  supplying 
the  vessel.1  This  fact  is  generally  explained  by  supposing  that 
irritation  of  the  dilating  nerves  has  an  inhibitory  action  upon 
local  vaso-motor  mechanisms  close  to  the  vessels,  though,  for 
my  own  part,  I  should  be  inclined  to  accept  the  much  simpler 
explanation  that  a  transverse  as  well  as  a  longitudinal  contrac- 
tion may  occur  in  the  muscular  cells  of  the  arterioles,  and  such 
a  transverse  contraction  would  elongate  each  cell  and  dilate  the 
vessel,  just  as  the  longitudinal  contraction  would  shorten  and 

1  Vide  Tigerstedt,  Lehrb.  d.  Physiol.  d.  Kreislaufs,  p.  512  (Leipzig:  Veit 
&  Co.,  1893). 


46 


THERAPEUTICS    OF    THE    CIRCULATION 


thicken  the  cell  and  thus  contract  the  vessel.  In  many  in- 
stances, dilatation  or  dilation  is  connected  with  peripheral  gan- 
glia ;  for  example,  in  the  sub-maxillary  gland  and  in  the  nervi 
erigentes,  but  that  it  is  always  due  to  such  nervous  causation 
is,  I  think,  doubtful.  For  a  good  while,  the  contractility  of 
capillaries  was  doubted,  but  the  observations  of  Strieker  and 
others  have  now,  I  think,  put  this  fact  be- 
yond dispute.1  When  working  under  Lud- 
wig's direction  I  also  noticed  that  local  irri- 
tation would  sometimes  cause,  not  contrac- 
tion, but  dilatation  of  an  arteriole.2  Similar 
observations  were  made  by  Gunning  and 
Cohnheim  in  the  frog;  so  that,  just  as  the 
effect  of  nerves  upon  the  heart  itself,  to  the 
exclusion  of  muscular  irritability,  is  now 
recognized  to  be  wrong,  so  in  all  probability 
the  properties  of  the  muscular  elements  of 
the  arterioles,  like  those  of  the  heart,  will  by 
FIG.  49.  Diagram  to  and  by  receive  more  attention  than  they  have 


hitherto  done. 

Rhythmical  Contraction  of  Vessels.- 


illustrate  the  hypothet- 
ical transverse  contrac- 
tion of  muscle.  (a) 
Muscle  in  relaxed  con- 

dition,  (&)  in  contrac-   Rhythmical   contraction   of   the   veins   was 

tion,    (c)  in  elongation. 

observed  to  exist  by  Wharton  Jones,3 
Schiff,4  and  Vulpian.5  The  arteries  also  contract  rhythmically 
under  the  influence  of  the  vaso-motor  center,  and  give  rise  to 
periodic  pulsations  which  are  coincident  with  respiration.  In 
addition  to  these,  however,  the  arteries  themselves  pulsate6 
periodically.7  It  is  difficult  to  see  this  pulsation  in  healthy 
people,  but  it  can  be  well  observed,  as  a  rule,  in  patients  suffer- 

1  Strieker,  Sits.  Ber.  d.  k.  k.  Akad.  d.  Wiss.  Math.-nat.  Cl,  1865,  41,  Abt. 
2-3,  51;  1866,  52;  1876,  Abt.  3,  316. 

2Lauder  Brunton,  Ludwig's  Arbeiten,  4ter  Jahrg.,  and  Collected  Papers 
on  Circulation  (First  Series,  pp.  160,  178). 

8  Wharton  Jones,  Phil.  Trans.,  1842,  p.  131. 

*  Schiff,  Arch.  d.  ges.  Physiol.,  xxvi.,  p.  456. 

6  Vulpian,  Mem.  Soc.  Biol.,  iii.,  1856,  p.  223,  and  1858,  p.  3. 

6  Schiff. 

7  Lauder  Brunton,  Ludwig's  Arbeiten,  4ter  Jahrg.,  1869. 


STIMULATION  OF  BLOOD-VESSELS EXTERNAL  47 

ing  from  aortic  regurgitation.  In  such  cases  the  face  is  usu- 
ally pale,  but  if  the  finger-nail  be  rapidly  drawn  across  the 
forehead,  a  red  streak  appears  which  alternately  widens  and 
narrows,  and  this  movement  on  careful  observation  will  be  seen 
to  show  three  rhythms.  The  first  coincides  with  the  pulse,  and 
occurs  between  sixty  and  seventy  times  per  minute ;  the  second 
with  respiration,  about  eighteen  or  twenty  times  per  minute; 
and  the  third,  or  capillary  rhythm,  is  only  about  three  times 
per  minute.1 

Stimulation  of  Blood-vessels  from  without. — It  is  difficult 


FIG.  50.      Vessels  in  the  web  of  a  frog's  foot  in  the  normal  condition  (after  Lister). 

to  explain  the  various  local  alterations  of  the  circulation,  if  we 
look  entirely  to  the  nervous  system  for  an  explanation  of  them ; 
whereas  the  explanation  is  easy  if  we  acknowledge  the  power 
of  vessels  to  contract  or  dilate  from  alterations  in  their  con- 
tractile element  apart  from  the  nervous,  although,  just  as  in 
the  heart,  we  must  fully  recognize  the  enormous  influence  of 
the  nervous  system  upon  the  vessels.  Thus,  when  we  apply  a 
mustard  poultice  to  the  skin  the  rapid  dilatation  of  the  vessels 
and  consequent  redness  which  immediately  follows  the  applica- 

1  Lander  Brunton,  Journ.  of  Physiol.,  1884,  vol.  v.,  p.  14. 


48 


THERAPEUTICS    OF    THE    CIRCULATION 


FIG.  51-      The  same  vessels  after  irritation. 


FIG.  52.  Apparatus  for  registering  muscular  contraction.  It  consists  of  an  up- 
right stand  on  which  two  horizontal  bars  may  be  moved  by  a  rack  and  pinion.  The 
upper  bar  ends  in  a  clamp,  the  lower  carries  a  delicate  lever,  the  part  near  the  hinge 
being  of  metal,  and  the  part  beyond  of  light  wood  tipped  with  quill  or  tinfoil.  a,  a 
Wires  for  exciting  muscle;  b,  muscle;  c,  writing  lever.  In  the  figure  no  arrange- 
ment is  shown  for  exciting  the  nerve,  and  for  the  sake  of  simplicity  the  weight  is 
shown  directly  under  the  muscle.  In  actual  experiment,  however,  the  weight  should 
be  applied  close  to  the  axle,  or  on  it,  so  as  to  lessen  oscillation  due  to  the  inertia  of 
the  lever. 


STIMULATION    OF    BLOOD-VESSELS INTERNAL 


49 


tion  are  probably  due  to  nervous  influence,  but  the  permanent 
redness,  which  may  remain  for  several  days,  is  more  likely  to 
be  due  to  a  local  alteration  in  the  .vessels  themselves.  (Fig. 

Si-) 

Stimulation  of  Vessels  from  within. — A  still  more  impor- 
tant question,  however,  than  the  effect  of  irritation  of  the  ves- 


Screw 


Screw 


Framework 


—  Clockwork 


ur 

FIG.  53.  Revolving  cylinder  for  recording  movements.  The  screws  at  the  top  are 
for  fixing  the  cylinder  in  position.  The  brass  pin  is  for  making  or  breaking  a  cur- 
rent at  a  given  time  in  the  revolution.  It  does  this  by  striking  against  a  small  key. 
The  curve  is  described  by  the  lever,  Fig.  73.  The  abscissa,  or  zero  line,  is  drawn 
by  a  fixed  point,  and  serves  to  show  the  height  of  the  contraction. 

sels  from  the  outside,  is  that  of  stimulation  from  the  inside  by 
various  products  of  tissue  waste  or  by  strain.  In  chronic  inter- 
stitial nephritis  the  blood  pressure  tends  to  rise  gradually,  so  as 
to  threaten  life  either  from  cardiac  failure  or  from  arterial  rup- 
ture. This  high  tension  appears  to  commence  by  increased 
resistance  to  the  passage  of  blood  through  the  arterioles  and 
5 


SO  THERAPEUTICS    OF    THE    CIRCULATION 

capillaries.     By  some  it  is  attributed  to  chronic  contraction  of 
the  arterioles  with  hypertrophy  of  their  muscular  walls,  by 


FIG.  54.      Tracing  of  the  normal  contraction  of  the  gastrocnemius  of  a  frog. 


FIG.  55.  Effect  of  heat  and  cold  on  muscle.  In  a  the  muscle  has  been  artificially 
warmed,  and  in  b  it  has  been  cooled.  Heat  makes  the  contraction  more  rapid,  cold 
makes  it  slower. 


FIG.   56.       Effect  of  fatigue  on  muscle. 


FIG.  57.  Tracing  of  the  contractions  of  a  muscle  with  stimuli  of  increasing  strength. 
The  numbers  indicate  the  distance  in  centimeters  of  the  secondary  from  the  primary 
coil  in  the  induction  apparatus.  As  and  Des  indicate  the  ascending  and  descending 
direction  of  the  current.  Cf.  Figs.  31  and  32. 

others  to  a  fibroid  thickening.  It  is  probable  that  both  of 
these  conditions  occur,  but  for  my  own  part  I  am  inclined  to 
believe  that  the  arterial  contraction  plays  a  very  great  part  in 


EFFECT    OF    HEAT    AND    COLD    ON    THE    CIRCULATION        5  I 

it,  as  we  are  able  to  reduce  the  tension  by  means  of  appropriate 
medicines,  such  as  nitrites,  which  one  would  hardly  do  if  it 
were  entirely  or  even  mainly  due  to  a  fibroid  condition. 

Effect  of  Heat  and  Cold  on  the  Circulation. — Two  agents 
which  have  a  very  marked  effect,  both  upon  the  vessels  and 
the  heart,  as  well  as  on  muscular  tissue  generally,  are  heat  and 
cold.  When  we  put  the  hand  into  hot  water  we  find  at  once 
that  the  arteries  dilate  and  the  hand  becomes  red,  showing  that 
the  capillary  circulation  is  free;  but  we  notice  also  that  the 
veins  not  only  become  full,  but  become  lighter  in  color,  evi- 
dencing that  the  blood  within  them  is  more  arterial.  Heat 
applied  to  the  heart  quickens  the  pulsations1  and  at  the  same 
time  increases  their  strength,  the  quickening  being  chiefly  due 
to  the  effect  of  the  heat  upon  the  sinus  or  auricles,  and  the 
increased  strength  to  its  effect  upon  the  ventricle.  (Fig.  59.) 
Cold  has  an  opposite  effect.  (Fig.  64.)  When  applied  to  the 
extremities,  it  makes  the  arteries  contract,  the  fingers  shrink 
and  become  pale,  though  after  a  while  the  veins  appear  to 
dilate,  and  the  skin  assumes  a  bluish  color  from  venous  conges- 
tion. Cold  applied  to  the  heart  makes  its  movements  both 
slower  and  feebler. 

It  is  evident  from  what  I  have  said  that  the  local  action  of 
either  heat  and  cold  upon  the  vessels  and  heart  is  of  such  a 
character  as  in  itself  to  coordinate  the  effect  it  produces  upon 
both,  independently  of  a  nervous  system,  if  applied  to  both  at 
the  same  time;  because  when  heat  causes  the  vessels  to  dilate, 
so  that  a  larger  supply  of  blood  is  demanded,  it  also  causes  the 
heart  to  pulsate  more  quickly  and  more  forcibly,  so  as  to  give 
the  necessary  supply.  When  the  arteries  are  contracted  by 
cold  and  a  small  amount  of  blood  only  can  pass  through  them, 
the  cold  acts  on  the  heart  also,  slowing  and  weakening  its  con- 
traction and  thus  lessening  the  supply.  But  while  cold  and 
heat  may  act  nearly  equally  upon  the  extremities  and  the  heart 
of  a  frog,  it  is  not  so  in  warm-blooded  animals,  where  the 

1  Lauder  Brunton,  St.  Bartholomew's  Hospital  Reports,  1871,  vol.  vii., 
and  Collected  Papers  (First  Series,  p.  204). 


THERAPEUTICS  OF  THE  CIRCULATION 

FIGS.  58  TO  67. — EFFECT  OF  COLD  AND  HEAT  ON 
THE  HEART. 


FIG.  58.  Tracing  of  the  beats  of  a  frog's  heart,  just  after  excision,  made  by  the 
author  with  a  simple  lever  (Fig.  20).  The  beats  are  abnormally  slow,  probably  from 
irritation  of  the  vagus  or  venous  sinus  during  excision. 


FIG.  59.  Tracing  from  the  same  heart,  in  which  the  beats  have  been  quickened  by 
heat  applied  by  placing  a  spirit  lamp  a  good  way  under  the  plate  on  which  the  heart 
rests. 


FIG.    60. — Continuation   of   Fig.    59.       The   heart   is  becoming   warmer,    and   the   beats 
become  quicker,  irregular,  and  intermittent. 


FIG.  61.  Continuation  of  Fig.  60.  The  heat  has  become  greater,  and  the  heart 
stops  in  heat  tetanus.  On  the  removal  of  the  spirit  lamp  the  beats  recommence,  but 
are  faint  and  irregular. 


FIG.  62.  Subsequent  extreme  slowing  by  placing  a  piece  of  ice  under  the  plate  on 
which  the  heart  rested.  The  tremors  are  probably  entirely  due  to  the  movement  of 
the  hand  holding  the  ice,  and  not  to  the  heart. 


EFFECT    OF    HEAT    AND    COLD    ON    THE    HEART 


53 


FIG.  63. 


Shows  the  spontaneous  recovery  after  removal  of  the  ice. 
in  groups  of  three. 


The  beats  occur 


FIG.  64.    Cold  was  reapplied,  and  the  beats  again  became  slow. 


FIG.   65.  .    Continuation   of  Fig.    64.       Increasing  slowness  of  the   beats  as  the   heart 

becomes  colder. 


FIG.  66.  The  first  part  of  the  tracing  shows  normal  beats,  the  heart  having  recov- 
ered from  the  effects  of  the  cold.  The  second  part  shows  the  effect  of  renewed  heating. 
The  slowness  is  probably  due  to  the  rapid  change  of  temperature  having  irritated  the 
vagus  ends  or  inhibitory  apparatus  in  the  heart. 


FIG.   67. 


Continuation   of  Fig.   66.       Shows  increased  slowness,   then  great  rapidity, 
and   final   stoppage   in   heat   rigor. 


54 


THERAPEUTICS    OF    THE    CIRCULATION 


temperature  of  the  interior  of  the  body  remains  nearly  the 
same,  notwithstanding  the  extremes  of  heat  and  cold  to  which 
the  extremities  may  be  subjected,  and  in  them  it  is  necessary 
to  have  a  nervous  system  to  regulate  the  pressure  of  blood. 


FIG.  68.  Author's  apparatus  for  ascertaining  the  effect  of  heat  and  cold  on  the 
vessels  of  the  frog's  lungs.  A,  a  piece  of  cork  to  which  the  frog  is  fastened,  is  laid  on 
B,  the  stage  of  a  microscope,  and  attached  by  an  india-rubber  strap,  C.  D  is  a  small 
ring  of  cork  covered  with  a  thin  circle  of  glass.  B  is  the  inflated  frog's  lung.  F  is 
a  tube  by  which  a  current  of  air  can  be  directed  on  the  frog's  lung.  It  is  held  in 
position  by  a  piece  of  wire,  G,  which  can  be  bent  to  any  position.  I  is  a  flask  con- 
taining ice  and  water.  H,  a  flask  containing  hot  water.  K  is  a  three-way  stopcock, 
by  which  a  current  of  air  may  be  sent  from  the  spray-producer,  L  and  M,  through 
tither  7  or  H  at  will,  and  thus  cold  or  hot  air  may  be  applied  alternately  to  the  lung. 


SCHEMA    OF    CIRCULATION HJEMODYNAMOMETER 


55 


FIG.  69.  Author's  schema  of  the  circulation.  It  consists  of  a  spray  producer, 
bladder,  and  mercurial  manometer.  The  elastic  ball  of  the  spray  producer  represents 
the  heart,  the  elastic  bag  covered  with  netting  to  prevent  too  great  distension  repre- 
sents the  aorta  and  arterial  system,  and  the  bladder  represents  the  venous  system. 


FIG.  70.  Marey's  haemodynamometer.  By  having  the  reservoir  of  mercury  very 
large,  the  descent  of  mercury  in  it  is  practically  negligible,  and  the  pressure  may  be 
read  off  directly  from  the  ascending  limb.  Two  tubes  are  attached.  In  one  the 
mercury  oscillates  rapidly,  with  variations  in  pressure.  In  the  other  there  is  a  con- 
striction, the  mercury  hardly  oscillates  at  all,  and  the  mean  pressure  is  thus  easily 
ascertained. 


50  THERAPEUTICS    OF    THE    CIRCULATION 

Effect  of  Heat  and  Cold  on  Pulmonary  Capillaries. — By 

means  of  the  apparatus  shown  in  Fig.  68,  I  found  that  if  a 
stream  of  warm  moist  air  be  first  directed  in  the  lung  of  a  frog., 
and  immediately  afterwards  a  stream  of  cold  moist  air.  the 


FIG.  71.  Ludwig's  kymograph,  copied  from  Ludwig's  Lehrbuch  der  Physiologic, 
2te  Auflage,  2ter  Band,  p.  122.  It  consists  of  a  bent  glass  tube,  abc,  containing 
mercury,  and  connected  by  d  with  the  artery  of  an  animal.  ef  is  a  slender  upright 
rod,  swimming  on  the  surface  of  the  mercury,  and  bearing  at  its  free  end,  /,  a  brush, 
g,  which  registers  the  movements  of  the  mercury  on  the  revolving  cylinder,  hh. 

capillaries  sometimes  contract  as  much  as  one-third  of  their 
diameter  under  the  influence  of  the  cold. — British  Medical 
Journal,  February  13,  1875. 


SCHEMA    OF    THE    CIRCULATION MANOMETER 


57 


Schema  of  the  Circulation. — I  have  here  a  simple  schema, 
consisting  of  an  india-rubber  ball  representing  a  heart,  an  elas- 
tic bulb  representing  the  arteries,  a  soft-walled  bag  represent- 
ing the  veins,  and  this  I  have  connected  with  a  mercurial 
manometer,  in  order  that  you  may  see  the  comparative  effects 
of  the  heart  and  vessels  upon  the  pressure  in  the  arterial  sys- 
tem. (Fig.  69.)  The  soft-walled  bag,  or  veins,  can  contain 


FIG.  72.  Registering  metallic  manometer  of  Marey.  m  is  the  capsule  of  an 
aneroid  barometer  filled  with  liquid.  T  is  a  tube  connecting  m  with  an  artery.  b  is 
a  mercurial  manometer,  which  can  either  be  put  in  communication  with  m,  and  the 
exact  pressure  in  it  and  the  artery  connected  with  it  ascertained,  or  may  be  cut  off 
by  the  stopcock.  *  is  a  registering  apparatus,  and  p  a  blackened  plate  on  which  the 
lever  writes.  When  the  stopcock  is  open  the  lever  will  record  the  oscillations  caused 
by  the  momentum  of  the  mercury,  but  if  it  be  shut  as  soon  as  the  actual  pressure 
has  been  ascertained,  only  the  actual  variations  in  the  blood  pressure  will  be  recorded. 

all  the  fluid  in  the  whole  vascular  system,  or  even  more,  so  that 
we  may  commence  with  the  pressure  at  zero.  As  the  india- 
rubber  ball,  which  I  may  shortly  call  the  heart,  is  emptied,  it 
drives  the  fluid  into  the  elastic  bulb,  or  arterial  system.  If  the 
passage  is  left  open  into  the  venous  bag,  the  mercurial  column 
oscillates  with  each  pulse,  rising  as  the  fluid  is  driven  in,  and 
sinking  again  in  the  interval.  But  if  I  slightly  turn  the  stop- 


THERAPEUTICS    OF    THE    CIRCULATION 


FIG.  73.  Tracing  of  the  oscil- 
lations in  a  mercurial  manometer. 
The  first  upward  stroke  is  due  to 
sudden  rise  of  pressure.  The 
subsequent  fall  below  zero  and 
the  other  oscillations  are  due  to 
the  inertia  of  the  mercury,  and 
not  to  any  external  force.  Com- 
pare with  Fig.  53. 


FIG.  74.  Tracing  made  with  one  of  Marey's  tam- 
bours. The  upward  strokes  correspond  to  rise  of  pres- 
sure in  the  tambour.  The  inertia  of  the  lever  is  very 
small,  and  consequently  there  are  no  secondary  falls 
below  the  zero  line,  nor  secondary  oscillations,  as  in  a 
mercurial  manometer.  Compare  with  Fig.  73. 


Writing  point. —  -\. 

Piston  to  lessen    | 
oscillation    of 
point 

Tube  filled  with 
glycerine 


Syringe  for  altering 
pressure  in  the 
manometer. 


Flat  metal  tube  form- 
ing the  manometer. 


Leaden  tube  to  con- 
nect the  manometer 
and  the  artery. 


FIG.  75.  Pick's  kymograph.  It  consists  of  a  flat  metal  tube,  bent  into  a  nearly 
circular  form,  filled  with  alcohol,  and  connected  with  the  artery  by  means  of  a  leaden 
tube,  filled  with  a  solution  of  sodium  carbonate.  When  the  pressure  increases  within 
it,  the  tube  straightens,  and  when  the  pressure  diminishes  it  bends.  These  changes 
are  magnified,  and  recorded  on  a  cylinder  by  a  light  lever.  The  vibrations  of  the 
lever  are  lessened  by  a  piston,  which  works  in  a  tube  filled  with  glycerine. 


KYMOGRAPHS 


59 


cock  so  as  to  prevent  all  the  fluid  driven  in  at  each  pulsation 
from  going  into  the  veins,  the  pressure  will  gradually  rise  in 
the  bulb  until  it  is  sufficient  to  drive  out  during  the  diastole  all 
the  fluid  sent  in  during  the  systole. 

Kymographs. — The  pressure  is  measured  in  animals  by 
putting  a  cannula  into  an  artery  and  connecting  it  with  a  mer- 
curial manometer.  In  order  to  prevent  coagulation,  the  tube 
leading  from  the  artery  to  the  manometer  is  filled  either  with 


A 


FIG.  76.  Diagram  to  illustrate  author's  method  of  combining  Ludwig's  and  Pick's 
kymographs  for  registering  the  blood  pressure  and  pulse.  A  is  the  cannula  for  inser- 
tion into  an  artery.  B  is  a  Y-tube  by  which  the  artery  can  be  put  in  communication 
either  with  a  mercurial  manometer  D,  or  a  Fick's  kymograph  F,  or  with  both  of 
them  at  the  same  time.  C  and  C'  are  two  clips  by  which  the  communication  of  either 
or  of  both  manometers  with  the  artery  can  be  shut  off  at  will,  or  a  three-way  stopcock 
may  be  employed  instead.  £  is  a  slowly  revolving  cylinder  on  which  the  mercurial 
manometer  registers  the  blood  pressure.  G  is  a  rapidly  revolving  cylinder  on  which 
the  Fick's  kymograph  registers  the  pulse  beats  from  time  to  time,  and  on  which  the 
respiration  can  also  be  registered.  (Phil.  Trans.,  1891,  vol.  clxxxii.) 

some  saline  solution,  or  solution  of  peptone,  which  hinders 
coagulation.  The  oscillations  of  the  mercurial  column  are 
recorded  on  a  revolving  cylinder,  and  the  whole  instrument, 
consisting  of  mercurial  manometer  and  recording  cylinder,  is 
called  a  kymograph. 

You  will  notice  that  when  the  mercury  is  once  set  into  oscil- 


6o 


THERAPEUTICS    OF   THE    CIRCULATION 


lation  it  continues  to  oscillate  for  a  length  of  time  after  the 
force  which  first  started  it  has  ceased,  and  in  this  way  prevents 
us  from  getting  any  exact  information  regarding  the  time  dur- 
ing which  the  force  has  acted.  (Fig.  73.) 

In  order  to  avoid  these  intrinsic  oscillations  other  recording 
instruments  have  been  employed,  such  as  the  spring  manometer 
of  Fick,  in  which  the  tension  causes  a  curved  tube  to  straighten 
or  bend  (Figs.  75  and  76),  or  the  manometers  of  Hurtle  or 
Roy,  where  the  oscillations  are  very  small,  but  are  much  mag- 
nified by  the  recording  lever. 

Blood  Pressure  in  Animals. — The  average  blood  pressure 
in  animals  varies  according  to  their  size,  but  not  to  the  extent 
that  we  should  imagine.  In  a  horse  it  has  been  found  to  be 
roughly  between  200  and  300  millimeters,  in  a  dog  140  to  170, 
in  a  sheep  150  to  170. 

Blood  Pressure  in  Man. — In  man  it  has  been  found  to  be 
from  100  to  I6O,1  in  cases  where  it  was  estimated  in  a  limb 
before  amputation. 


FIG.  77.  a,  Simple  instrument  for  measuring  the  blood  pressure  in  an  artery. 
b,  In  this  an  improvement  has  been  made  on  the  simple  form  by  adding  a  side  spring 
catch,  which  obviates  the  necessity  of  reading  the  index  before  removing  it  from 
the  arm. 

Measurement  of  the  Blood  Pressure  in  Man. — It  is  nat- 
urally of  very  great  importance  that  we  should  be  able  to  esti- 
mate the  pressure  in  man,  and  numerous  instruments  have  been 
devised  for  this  purpose. 

By  simply  feeling  the  pulse  with  a  finger,  one  can  roughly 

1  Faivre  and  Albert,  quoted  by  Tigerstedt,  Lehrb.  d.  Physiol.  d.  Kreis- 
laufs,  p.  329  (Leipzig:  Veit  &  Co.,  1893). 


MEASUREMENT    OF    BLOOD    PRESSURE    IN    MAN 


6l 


make  out  whether  the  pressure  within  it  is  high  or  low,  and 
this  is  still  better  done  by  placing  three  fingers  upon  the  pulse 


FIG.  78.  Shows  the  mode  of  applying  the  simple  sphygmomanometer,  by  pressing 
it  directly  on  the  palpating  finger  instead  of  pressing  it  on  the  artery,  and  feeling 
the  artery  nearer  the  hand.  (After  Verdin.) 

and  compressing  it  with  the  one  nearest  the  heart  and  noticing 
with  the  middle  one  when  it  ceases  to  beat.     By  the  amount 


FIG.  79.  Shows  an  instrument  in  which  the  movements  of  the  spring  are  magnified 
and  read  off  on  a  dial.  There  is  a  movable  index  which  is  pushed  on  by  the  indicator, 
and  left  at  the  maximum  point.  (After  Verdin.) 

of  pressure  exercised,  one  can  form  some  judgment  regarding 
the  tension,  but  it  is  evident  that  one  cannot  convey  any  quan- 
titative knowledge  regarding  the  pulse  felt  this  way  to  another. 


62 


THERAPEUTICS    OF    THE    CIRCULATION 


The  third  finger  nearest  the  hand  compresses  the  artery  so  as 
to  obstruct  the  recurrent  pulse  from  blood  flowing  through  the 
ulnar  artery  and  palmar  arch. 

Instruments  for  Measuring  the  Blood  Pressure  in  Man. 


FIG.  80.      Instrum 


of  blood  in  the  capillaries. 


—These  may  be  roughly  divided  into  two  classes :  ( i )  those 
which  compress  a  single  artery;  (2)  those  which  compress  a 
digit  or  limb.  One  instrument  of  the  first  class  is  simply  a 
little  knob  attached  to  a  graduated  scale 
in  a  spring  balance,  like  what  is  often 
used  for  weighing  letters.  (Figs.  77  and 
78.)  The  movement  of  the  scale  here  is 
so  small  that  it  is  practically  of  little  use. 
In  another  more  elaborate  one  the  move- 
ment is  multiplied  by  a  wheel,  so  that  the 
pointer  shows  the  pressure  on  a  large  dial 
(Fig.  79),  but  this  instrument  also  is  un- 
satisfactory, as  it  is  difficult  to  apply  it 
directly  over  the  vessel,  and  the  data  ob- 
tained from  it  are  not  very  trustworthy. 
Better  and  more  exact  results  are  obtained 
by  the  substitution  of  a  fluid  of  a  solid 
pad.  So  far  as  I  know,  the  first  man  to 
use  a  fluid  pad  over  the  artery  was  Heris- 
son.  His  instrument  consisted  of  a  small 
funnel  covered  at  its  larger  end  by  a  thin 
membrane,  and  having  a  long  graduated 
glass  stem  at  its  other  end.  (Fig.  81.) 
The  whole  apparatus  was  filled  with  mer- 
cury. The  simple  apparatus  of  this  sort 
which  I  now  show  you  was  made  by  Professor  Waller.  "\Yhen 
it  is  placed  upon  the  radial  artery  you  see  the  mercury  oscillat- 
ing with  each  beat,  and  by  and  by  when  the  pressure  applied 


FIG.  8 1.  Sphygmoma- 
nometer  of  Herisson. 
(After  Marey.)  • 


VON    BASCH  S    SPHYGMOMANOMETER 


to  the  vessel  becomes  sufficiently  great  the  pulsations  below  the 
instrument  cease. 

The  disadvantage  of  Herisson's  instrument  and  others  made 
upon  the  same  pattern  is,  that  it  is  very  difficult  to  keep  the 
mercury  from  oozing  out  between  the  end  of  the  funnel  and 


--Graduated  tube 


lj|--Water 

Opening  in 
glass  bulb 

Mercury 
Glass  bulb 


Brass  collar 

Membranfj 


-Graduated  tube 
-Rubber  stopper 

^-^  -Water 

-Bulb 
--  Mercury 


-  Rubber  stopper 

>  with  central  hole 

Grounded  lower 

end 

--Membrane 


«  b 

FIG.  82.  Early  form  of  Von  Basch's  sphygmomanometer  (a).  The  lower  part, 
showing  the  india-rubber  or  oil-silk  cap,  is  not  quite  correct,  as  this  part  of  the  instru- 
ment in  the  author's  possession  has  been  lost,  b  shows  the  author's  cheap  modification 
made  by  Messrs.  Cetti  &  Co. 

the  membrane  which  covers  it.  To  obviate  this  difficulty,  my 
old  friend  Von  Basch  enclosed  the  mercury  in  a  glass  bulb 
into  which  the  glass  tube  passed.  This  was  then  enclosed  in 
an  outer  cylinder  the  lower  end  of  which  was  covered  by 
membrane,  and  which  was  filled  with  water,  which  trans- 
mitted the  pressure  to  the  mercury  through  a  small  hole  in 
the  bulb.  This  manometer  was  screwed  into  a  stand  in 
which  the  wrist  was  clamped,  and  the  manometer  gently 
depressed  on  the  radial  until  the  pulsation  ceased,  as  was 


64 


THERAPEUTICS    OF   THE    CIRCULATION 


indicated  by  a  small  pad  resting  on  the  artery  and  communi- 
cating with  a  Marey's  tambour.  This  was  the  first  instru- 
ment of  real  practical  use,  and  although  Herisson's  instru- 
ment was  long  anterior,  yet  Von  Basch  must,  I  think,  be  re- 


FIG.  83.  Von  Basch's  sphygmomanometer  and  stand.  Drawn  from  one  in  the 
author's  possession.  A  is  the  india-rubber  cap  of  the  sphygmomanometer  resting  on 
the  radial  artery.  B  is  a  metal  ring  which  holds  the  sphygmomanometer,  and  can  be 
raised  or  lowered  at  will  by  the  screw  C.  D  is  the  stand  in  which  the  arm  rests. 
£  is  a  sliding  piece  which  holds  the  arm  in  position,  and  also  supports  the  sphygmo- 
graph  I.  F  is  a  screw  to  fix  £  in  position.  G  is  a  fixed  projection  at  the  other  end 
of  D,  and  the  wrist  is  clamped  between  E  and  G.  G  consists  of  two  parts,  one  of 
which  is  quite  fixed;  the  other,  indicated  by  K,  can  be  pressed  more  or  less  firmly 
against  the  arm  by  a  fine  screw  not  shown  in  the  drawing.  H  is  a  fine  screw  by  which 
the  tambour  of  the  sphygmograph  can  be  raised  or  lowered  so  that  it  rests  with  more 
or  less  pressure  on  the  top  of  the  rod  which  passes  up  from  a  small  pad  which  rests 
in  the  artery.  K  indicates  the  position  of  this  pad  as  well  as  of  the  movable  piece 
of  G.  L  is  a  joint  in  which  a  lever  plays,  the  outer  end  of  which  is  fixed  to  the 
pad  K,  and  keeps  it  moving  in  a  perpendicular  line.  M  is  a  joint  allowing  of  con- 
siderable horizontal  play  backwards,  forwards,  laterally,  and  circularly,  so  that  the 
sphygmograph  may  be  accurately  adjusted  over  the  artery.  N  is  a  screw  by  which 
the  whole  sphygmograph  may  be  moved  up  and  down  on  the  stand  O.  P  is  one  of 
Marey's  tambours,  communicating  by  a  piece  of  elastic  tubing  with  the  tambour  of  the 
sphygmograph,  and  writing  the  pulse  on  the  blackened  cylinder  V.  R  is  a  screw  work- 
ing on  a  spring,  by  which  the  resistance  of  the  lever  resting  on  the  tambour  may  be 
adjusted.  S  is  a  screw  by  which  the  tambour  may  be  moved  up  and  down  on  the 
stand  T.  F  is  a  revolving  cylinder  covered  with  blackened  paper,  on  which  the 
tracing  is  taken.  It  is  moved  by  clockwork,  which  is  not  shown  in  the  drawing. 


VON    BASCH  S    SPHYGMOMANOMETER  65 

garded  as  the  practical  founder*  of  the  measurement  of  blood 
pressure  in  man.     (Figs.  82  and  83.) 

A  good  many  years  ago  I  got  Mr.  Cetti,  of  Brook  Street, 
Holborn,  to  make  up  instruments  of  this  sort  for  me  for  use  in 
the  wards  at  St.  Bartholomew's  Hospital.  Instead  of  the 
metal  collars  at  the  ends  of  the  cylinder,  I  used  two  rubber 
stoppers  with  a  hole  in  the  center  of  each.  Through  the  upper 
one  passed  the  stem  of  the  manometer.  The  lower  end  of  the 
other  stopper  was  rounded  at  the  edges,  so  that  the  membrane 
fitted  better  over  it,  and  it  could  be  applied  more  easily  to  the 
artery.  These  instruments  Mr.  Cetti  manufactured  for  a  few 


FIG.  84.  Von  Basch's  sphygmomanometer,  from  a  specimen  in  the  possession  of  the 
author.  A  is  a  three-way  stopcock,  by  which  the  aneroid  B  can  be  put  in  communica- 
tion either  with  the  bulb  C  or  with  the  outer  air.  This  is  not  the  first  form  of  Von 
Basch's  sphygmomanometer.  The  bulb  which  he  first  used  was  included  in  a  metal 
case  somewhat  resembling  Marey's  cardiograph.  My  instrument  needed  repair,  so  I 
sent  it  to  Vienna,  and  it  was  returned  by  the  maker,  with  the  bulb  figured  above. 

shillings.  I  found  a  small  stopcock  in  the  upper  stopper  use- 
ful for  the  removal  of  air-bubbles,  and  complete  filling  of  the 
cylinder  with  water.  (Fig.  826). 

The  instrument  had  the  great  disadvantage  of  not  being 
portable.    Unless  it  was  kept  upright  and  was  not  shaken,  the 
mercury  and  water  became  mixed,  and  the  instrument  was  use- 
6 


66 


THERAPEUTICS    OF    THE    CIRCULATION 


FIG.  85.      Potain's  modification  of  Von  Basch's  sphygmomanometer.      This  is  made  by 
M.  Boulitte,  successor  to  M.  Charles  Verdin,  7  Rue  Linne,  Paris. 

less  for  the  time.  It  was  therefore  of  little  value  for  clinical 
work.  Von  Basch  accordingly  invented  another  model,  in 
which  pressure  was  applied  over  the  artery  by  a  metal  cap 
covered  at  one  end  by  a  thin  membrane,  and  communicating 


FIG.  86.  Mode  of  applying  Potain's  sphygmomanometer.  This  figure  is  not  quite 
correct,  for  it  is  better  to  place  the  palpitating  finger  parallel  to  the  artery  instead  of 
at  right  angles  to  it.  Only  one  finger  should  be  used  to  feel  the  pulse,  as,  if  two 
are  used,  the  elastic  bulb  is  pushed  too  high  above  the  end  of  the  radius,  and  too 
high  a  reading  is  obtained. 


OLIVER  S    SPHYGMOMANOMETER  67 

at  the  other  by  a  thick-walled  rubber  tube  with  an  aneroid 
barometer  graduated  in  millimeters  of  mercury.  In  a  later 
model  the  metal  ring  communicated  with  the  aneroid  by  an 
opening  in  its  side ;  one  end  was  covered  with  thin  india-rubber 
for  application  over  the  artery,  and  the  other  with  thick  india- 


FIG.  87.      Most  recent  form  of  Von  Basch's  sphygmomanometer. 


rubber  on  which  the  finger  was  pressed  until  the  pressure  in- 
side the  apparatus  was  sufficient  to  stop  the  pulse.  (Fig.  84.) 
A  further  improvement  was  introduced  by  Potain,  who 
replaced  the  metal  ring  by  moderately  thick  rubber,  so  that 
the  bulb  for  application  over  the  radial  consists  of  thin  rubber 


FIG.  88.  Oliver's  Sphygmomanometer.  Instead  of  the  pad  which  rests  on  the 
artery  being  solid,  it  consists  of  an  elastic  capsule  containing  fluid.  This  is  made  by 
Mr.  Hawksley,  357  Oxford  Street,  London. 

at  the  side  which  lies  against  the  wrist,  thick  rubber  (usually 
of  a  red  color)  at  the  opposite  side  on  which  the  compressing 
finger  rests,  and  moderately  thick  rubber  between.  With  this 
exception,  Potain's  instrument  is  the  same  as  Von  Basch's 
(Fig.  85). 


68 


THERAPEUTICS    OF    THE    CIRCULATION 


The  latest  form  of  Von  Basch's  apparatus  is  still  simpler, 
and  consists  of  an  elongated  rubber  bag  of  the  same  thickness 
in  every  part.1  (Fig.  86.) 

Fallacies  in  Applying  Von  Basch's  or  Potain's  Instru- 
ments.— Unless  the  elastic  bulb  is  placed  above  the  end  of  the 
radius,  and  not  over  the  soft  tissues,  so  that  the  artery  can  be 
compressed  between  it  and  the  bone,  too  high  a  reading  is 


FIG. 


Pick's    apparatus   for   measuring   and   recording   changes   in   the   volume   of 
organs.       (After   Marey.) 


obtained.  If  the  palmar  arch  is  dilated  the  recurrent  pulse 
through  it  from  the  ulnar  artery  may  cause  pulsation  to  be 
felt  after  the  radial  has  been  completely  compressed  by  the 
bulb.  To  avoid  this  the  palpating  finger  should  be  placed  on 
the  radial  artery  with  the  tip  pointing  upwards.  Any  recur- 
rent pulse  is  then  stopped  by  the  pulp  of  the  finger,  and  the 
central  radial  pulse  is  felt  by  the  finger  tip. 

Another  apparatus  which  also  depends  on  the  application  of 
a  fluid  bulb  over  the  pulse,  is  a  very  neat  little  one  invented  by 
Mr.  Leonard  Hill.  Like  Herisson's,  it  consists  of  a  funnel 
closed  at  one  end  by  a  thin  membrane.  The  funnel  is  very 
flat,  and  Mr.  Hill  has  avoided  the  difficulty  of  using  mercury, 
and  has  rendered  the  instrument  portable  by  employing  a 

1  This  is  made  in  Vienna,  but  can  be  obtained  from  Messrs.  Down  Bros., 
21  St.  Thomas's  Street,  S.  W.,  London. 


FALLACIES    OF    BULB    INSTRUMENTS 


69 


colored  liquid  having  no  weight  in  itself,  but  working  against 
the  resistance  of  a  column  of  air  prevented  from  escaping  by 
a  stop-cock  at  the  upper  end  of  the  tube,  and  compressed  by 
any  pressure  on  the  membrane.  It  is  very  light  and  portable, 
but  unless  a  good  deal  of  care  is  taken,  air-bubbles  are  apt 
to  become  mixed  with  the  liquid,  and  cause  some  loss  of  time 
before  they  can  be  got  rid  of.  Oliver's  hsemodynamometer 
has,  like  those  just  described,  a  fluid  pad  consisting  of  thin 


FIG.  90.  Mosso's  plethysmograph.  A  is  a  glass  vessel  filled  with  oil  or  water  in 
which  the  arm  is  inserted  and  the  liquid  prevented  from  escaping  by  an  india-rubber 
cap.  t  is  a  thermometer,  b  an  opening  for  filling  or  emptying  the  apparatus.  When 
the  arm  swells,  a  little  of  the  fluid  passes  from  the  glass  vessel  through  the  tube  a 
into  the  test-tube  B,  which  is  thus  rendered  heavier,  and  by  a  thread  running  over  a 
pulley  raises  the  writing  point  and  registers  the  increased  size  of  the  arm.  When  the 
vessels  of  the  arm  contract,  its  size  diminishes,  fluid  returns  into  A  and  the  writing 
point  falls.  c  is  a  vessel  containing  water,  in  which  the  tube  B  is  partially  immersed 
so  that  its  weight  is  counterbalanced.  £  is  a  burette  which  can  be  made  to  com- 
municate or  clamped  off  at  will,  and  the  quantity  of  fluid  in  B  regulated  to  a  nicety. 

rubber  filled  with  water  and  glycerine,  for  application  over  the 
artery.  The  pressure  from  this  pad  is  not  conveyed  from  its 
interior  to  a  recording  apparatus,  but  by  a  rod,  one  end  of 


THERAPEUTICS    OF   THE    CIRCULATION 


FIG.  91.  This  is  a  combination  of  the  plethysmograph  with 
Marey's  metallic  manometer.  By  raising  or  depressing  the  vessel 
R  the  pressure  inside  the'  plethysmograph  may  be  increased  or 
diminished  at  will,  and  the  pressure  measured  by  noting  the 
point  of  maximum  oscillation  or  entire  arrest  of  pulsation. 
(After  Verdin.) 


BAND    INSTRUMENTS    FOR    ESTIMATING    BLOOD    PRESSURE 


which  rests  upon  it  whilst  the  other  presses  in  a  spring.  The 
motion  of  the  spring  is  shown,  greatly  magnified,  by  an  index, 
which  moves  over  a  scale  1 1  inches  long,  but  conveniently  ar- 
ranged in  the  form  of  a  helix  on  a  dial  2  inches  in  diameter. 
Band  Instruments  for  Estimating  Blood  Pressure. — In- 
struments belonging  to  the  second  class,  viz.  encircling  a  digit 
or  a  limb,  were  first  used  by  Piegu,  Chelius,  Pick,  Buisson, 
Marey,  Mosso,  and  Frangois  to  measure  the  volume  of  blood 
which  enters  a  limb  at  each  pulse,  and  show  the  kind  of  pulsa- 
tion in  them  under  various  conditions  of  the  circulation  rather 
than  to  measure  the  pressure  of  blood  in  the  arteries.  Piegu 
enclosed  an  entire  limb  in  a  vessel  filled  with  tepid  water,  and 
furnished  with  a  narrow  tube  in  which  the  water  could  be 


•8* 


FIG.   92.      Marey's  apparatus  for  measuring  the  blood  pressure  in  a  finger. 

seen  to  rise  and  fall  with  each  pulsation.  Chelius  and  Pick 
independently  connected  this  tube  with  Ludwig's  kymograph, 
and  were  thus  able  to  obtain  tracings  of  the  variations.  The 
apparatus  was  perfected  by  A.  Mosso,  who  gave  it  the  name 
of  plethysmograph. 


72  THERAPEUTICS    OF   THE    CIRCULATION 

When  the  pressure  in  such  an  instrument  is  artificially  raised 
the  oscillations  increase  up  to  a  certain  maximum,  then  dimin- 
ish, and  finally  cease.  The  maximum  is  considered  to  repre- 
sent the  diastolic  pressure  in  the  arteries,  and  the  cessation  to 
be  equal  to  the  systolic  pressure.  It  is  not  easy  to  prevent 


FIG.  93.  Mosso's  sphygmomanometer.  It  consists  of  metal  tubes  (££)  filled 
with  water,  which  is  prevented  from  coming  out  by  india-rubber  finger-stalls  into 
which  the  fingers  are  inserted.  The  apparatus  is  then  quite  filled  with  water  from  the 
bottle  B,  air  being  allowed  to  escape  at  C.  The  pressure  is  then  raised  by  com- 
pressing the  water  in  the  reservoir  (A)  by  the  screw  at  its  top  until  the  mercury  in 
the  manometer  (G)  registers  the  maximum  oscillation,  which  may  be  taken  as  the 
diastolic  pressure.  The  pressure  is  then  raised  until  the  mercury  ceases  to  oscillate, 
and  this  may  be  taken  as  the  systolic  pressure. 

leakage  when  the  pressure  is  raised  in  an  instrument  where  the 
limb  is  immersed  directly  in  the  fluid,  for  it  is  apt  to  exude 
between  the  skin  and  the  rubber  collar  surrounding  the  limb, 


PLETHYSMOGRAPHS 


73 


unless  the  ligature  is  so  tight  as  both  to  be  very  uncomfortable 
to  the  subject,  and  to  interfere  with  the  circulation. 

Marey1  and  Mosso  both  overcame  this  difficulty,  by  enclos- 
ing liquid  by  a  thin  membrane  through  which  the  pulsations 
of  the  finger  or  limb  were  transmitted.  In  Marey's  instrument 


FIG.  94.      Plethysmograph  of  Hallion  and  Comte. 

only  one  finger  was  enclosed,  while  in  Mosso's  four  fingers  are 
introduced  into  the  sphygmomanometer.  In  both  of  these 
instruments  the  pressure  is  raised  artificially  by  driving  in  air 
or  water,  until  the  oscillations  of  the  manometer  reach  a 
maximum,  and  then  pushing  the  pressure  till  they  cease  alto- 
gether, and  the  circulation  in  the  fingers  is  stopped.  By  re- 
laxing the  pressure  the  oscillations  again  reach  a  maximum  as 
the  circulation  again  returns.  In  this  way,  a  double  observa- 
tion is  made. 

In  Gaertner's  tonometer  the  pressure  is  measured  by  empty- 
ing a  finger  of  blood,  and  noting  under  what  pressure  the 
circulation  returns.  (Fig.  95.) 

It  consists  of  a  metal  ring  1.5  cm.  broad,  to  the  inside  of 
which  an  india-rubber  membrane  is  fixed,  so  as  to  leave  an  air 
space  between  it  and  the  ring.  This  space  communicates  by  an 

1  Marey,  Trav.  Lab.,  torn,  ii.,  p.  31.3. 


74 


THERAPEUTICS    OF   THE    CIRCULATION 


FIG.  95.      Gaertner's  tonometer. 

opening  in  the  side  of  the  ring,  and  a  T-tube  with  a  mercurial 
manometer  and  a  pressure  ball  consisting  of  a  closed  india- 
rubber  bag  compressed  in  a  wooden  vise.  An  open  bag  with 
good  valves  and  adjustable  outlet  may  be  employed  instead. 
This  is  placed  loosely  on  the  middle  phalanx  of  one  finger,  and 


MODE    OF    USING    GAERTNER  S    TONOMETER 


75 


the  blood  pressed  out  of  the  last  phalanx  either  by  rolling  a 
thick  narrow  india-rubber  ring  upwards,  or  by  wrapping  a  piece 


FIG.   96.      Gaertner's  tonometer,   portable  fo 


FIG.  97.      Mode  of  using  Gaertner's  tonometer. 


of  fine  india-rubber  tubing  tightly  round  the  finger  from  its 
tip  upwards.     The  pressure  is  then  raised  in  the  apparatus  to 


76 


THERAPEUTICS    OF    THE    CIRCULATION 


a  point  which  is  certain  to  be  above  the  pressure  in  the  arteries, 
e.  g.,  200  mm.  of  mercury.  The  india-rubber  ring  is  then 
rolled  off  or  the  tube  unwound,  leaving  the  last  phalanx  white 
and  bloodless.  The  pressure  is  then  lessened  and  the  finger- 
tip watched,  so  as  carefully  to  note  when  it  begins  to  flush 
with  the  returning  circulation.  The  height  of  the  mercurial 


FIG.  98.  Combined  Potain's  and  Gaertner's  apparatus.  AP  is  Potain's  bulb. 
DG  is  Gaertner's  tonometer.  P  is  an  india-rubber  bulb  containing  air,  by  which 
the  pressure  can  be  raised  in  the  tonometer.  M  is  an  aneroid  manometer.  R',  R" 
and  R'"  are  stopcocks  by  which  communication  can  be  established  at  will  between  the 
various  parts  of  the  apparatus. 

column  at  this  moment  indicates  the  systolic  pressure  in  the 
digital  arteries. 

For  ordinary  bedside  work,  Professor  Gaertner  replaces  the 
mercurial  by  an  aneroid  manometer,  and  thus  renders  his 
instrument  convenient  and  portable.  (Fig.  96.) 


LECTURE    III 

Measurement  of  the  Blood  Pressure  in  Man  (continued)  :  Instruments 
of  Riva-Rocci,  Hill  and  Barnard,  Martin,  and  others;  Author's  arrange- 
ment— Systolic  and  Diastolic  Pressures — Standardization  of  Instruments 
— Measurement  of  the  Size  of  an  Artery — Oliver's  Arteriometer — Measure- 
ment of  Pressure  in  the  Veins — Measurement  of  Pressure  in  the  Cap- 
illaries— Measurement  of  the  Volume  of  Organs — Plethysrhographs — Car- 
diographs— Sphygmographs — Forms  of  Sphygmograph  :  Marey's,  Ludwig 
and  Von  Frey's,  Dudgeon's,  Jacquet's,  Laulanie's — Size  of  Vessels — • 
Cardiograph  and  Sphygmograph — Sphygmograms — Retardation  of  Pulse- 
wave — Nutrition  of  the  Heart — Self-massage  of  the  Heart — Brucke's 
View — Nutritive  Action  of  Cardiac  Tonics — Self-massage  of  the  Arteries. 
PATHOLOGY  OF  THE  CIRCULATION — Effect  of  Altered  Quality  of  Blood — 
Blocking  of  Coronary  Arteries — Effect  of  Feebleness  of  the  Heart  on  the 
Nutrition  of  Blood-vessels — Nervous  Depression — Fatty  Degeneration — 
Pulse-rate — Exophthalmic  Goitre. 

PERHAPS  the  most  practically  useful  of  all  the  instruments 
for  estimating  the  blood  pressure  in  man  is  that  invented  by 
Riva-Rocci,  with  its  numerous  alterations  and  improvements. 
It  consists  of  an  elongated  distensible  but  resistant  bag  con- 
nected with  a  mercurial  manometer  (Fig.  99).  The  bag  is 
fastened  round  the  arm  and  inflated  by  a  small  india-rubber 
hand-pump  until  the  pressure  is  sufficiently  great  to  stop  the 
pulse.  This  point  is  noted,  and  the  pressure  is  then  increased 
a  little  further;  air  is  then  gradually  let  out,  and  the  pressure 
is  again  noted  when  the  pulse  begins  to  reappear.  In  this 
way  one  has  actually  two  observations  made  close  together  of 
the  pressure  which  stops  the  flow  of  blood  in  the  artery.  The 
objections  to  the  instrument  in  its  original  form  are  that  the 
narrow  band  appears  to  give  a  higher  reading  than  what  is 
attained  by  a  broader  one,  and  that  mercurial  manometers  are 
always  inconvenient  for  carrying  about.  Hill  and  Barnard 
have  made  an  instrument  in  which  these  objections  are  avoided, 
by  making  the  band  broader,  by  making  its  outside  of  leather 
so  that  it  does  not  yield,  and  its  inside  of  thin  rubber,  and  by 

77 


7<5  THERAPEUTICS    OF   THE    CIRCULATION 

employing  an  aneroid  instead  of  a  mercurial  manometer.1 
Another  modification  is  Martin's,  in  which  the  band  is  made  of 
soft  pliable  metal  covered  with  cloth,  and  it  is  sufficiently  broad 
to  overlap  the  elastic  bag  by  about  half  an  inch  on  either  side, 
and  thus  prevent  the  bag  being  blown  out  to  one  side.2  He 
has  also  added  a  convenient  screw  valve,  by  which  the  air  may 
be  allowed  to  pass  out  of  the  apparatus  very  slowly  and  the 


FIG.    99.       Riva-Rocci's  sphygmomanometer. 

pressure  to  diminish  very  gradually.  Martin  retains  the  mer- 
curial manometer,  so  that  this  is  inconvenient  for  carrying 
about.  I  have  had  one  made  which  I  think  is  more  convenient 
than  any  of  the  others,  but  I  can  hardly  claim  it  as  my  own, 
because  it  is  simply  a  patchwork  of  pieces  from  one  instrument 
and  pieces  from  another.  (Fig.  100.)  The  principle  of  the 

1  Hill  and  Barnard.  *  C.  J.  Martin. 


AUTHORS    APPARATUS 


79 


band  is  Riva-Rocci's ;  the  broad  band  I  have  copied  from 
Martin,  but  have  substituted  a  piece  of  unyielding  tissue  which 
is  light  to  carry,  in  place  of  the  heavier  metal;  the  principle 
of  the  aneroid  is  Von  Basch's,  the  particular  modification  of 
it  is  Potain's.  By  combining  all  these  parts  together,  however, 


FIG.  100.  The  author's  modified  Riva-Rocci  band.  AB  is  a  band  of  thin  gutta 
percha  inside  which  is  a  narrower  india-rubber  bag  C.  D  are  three  straps  to  fasten 
the  band  round  the  arm.  £  is  a  tube  leading  into  the  bag  C,  and  allowing  air  to 
pass  from  it  either  to  a  mercurial  or  aneroid  manometer.  In  using  it  along  with  the 
other  instruments,  all  that  is  necessary  is  to  detach  the  tonometer  DG,  Fig.  81,  and 
replace  it  by  the  band.  A  spray-producer  ball,  like  that  in  Fig.  81,  should  also  be 
used  instead  of  the  simple  bulb  P,  or  a  small  one  with  Martin's  valve  may  be  em- 
ployed. For  practice  one  rarely  needs  all  three,  and  Potain's  bulb  with  the  band 
and  aneroid  are  all  that  are  necessary. 

I  have  obtained  a  very  convenient  instrument  by  which  we  can 
in  a  few  minutes  measure  the  tension  of  the  blood  in  the 
radial  artery  by  pressure  upon  it  with  Potain's  bulb,  and  con- 
trol this  observation  by  means  of  Gaertner's  tonometer,  or  by 
measuring  the  pressure  in  the  arm  necessary  to  stop  the  radial 
pulse  with  the  modified  Riva-Rocci  band.  I  have  been  making 
a  number  of  comparative  experiments  in  regard  to  the  ten- 
sion in  man,  as  ascertained  by  different  instruments,  and  have 
been  rather  disappointed  by  the  want  of  concordance  between 
the  results.  Using  these  three  instruments  together,  however, 
I  am  certain  of  obtaining  results  which  agree  very  well  with 
one  another. 

Many  modifications  of  Riva-Rocci's  instrument  have  been 
made  and  used  in  America.  They  are  described  by  Janeway1 

1T.  C.  Janeway,  "The  Clinical  Study  of  Blood  Pressure"  (New  York 
and  London:  Appleton  &  Co.),  1004. 


8O  THERAPEUTICS    OF    THE    CIRCULATION 

in  his  work  on  "  The  Clinical  Study  of  Blood  Pressure,"  but 
I  do  not  think  it  necessary  to  describe  them  fully  here.     I  may 


FIG.   101.      Author's  arrangement  for  using  a  broad  Riva-Rocci  band  with  Von  Basch's 
or  Potain's  sphygmomanometer  instead  of  a  mercurial  manometer. 

merely  mention  that  the  principal  are  Stanton's,  Janeway's 
and  Erlang-er's.     They  are  all  modifications  of  Riva-Rocci's. 


AMERICAN    SPHYGMOMANOMETERS 


8l 


Janeway's  has  the  mercurial  manometer  jointed  for  conveni- 
ence of  carriage,  and  Erlanger's  has  a  large  sphygmoscope  at- 
tached, which  enabled  the  alterations  in  pressure  to  be  recorded 


FIG.  102.  Marey's  Improved  Metallic  Manometer.  This  was  originally  intended 
to  be  connected  to  an  artery,  but  I  find  it  can  be  connected  to  an  armlet,  or  used 
to  measure  the  blood  pressure  in  the  same  way  as  Riva-Rocci's,  while  at  the  same 
time  tracings  can  be  got  of  the  pulse.  (Cf.  Fig.  91,  p.  70.)  It  consists  of  a  flat, 
metallic  vessel  B  in  which  the  capsule  of  an  aneroid  barometer  filled  with  liquid  is 
fixed,  CA.  To  this  leads  an  afferent  tube  T,  which  is  put  in  communication  with 
the  artery,  the  pressure  in  which  is  to  be  measured.  An  efferent  tube  Y,  leads  to 
a  mercurial  manometer,  which  indicates  the  absolute  pressure  and  controls  the  readings 
of  the  metallic  manometer.  The  metallic  vessel  B  has  at  its  upper  part  a  glass  tube 
TV,  and  is  filled  with  water  which  rises  a  little  way  up  in  the  glass  tube.  The 
upper  part  of  this  tube  is  closed  by  a  caoutchouc  stopper,  through  which  a  tube  T 
passes;  this  tube  is  connected  by  a  piece  of  elastic  tubing  with  one  of  Marey's  tam- 
bours, which  records  the  oscillations  of  the  aneroid  capsule.  By  means  of  the  stop- 
cock R,  the  metallic  may  be  separated  from  the  mercurial  manometer;  P  is  a  pair 
of  pincers  closing  an  exit  tube,  by  which  the  instrument  can  be  either  emptied  or 
filled,  or  the  tension  lowered. 

on  a  revolving  cylinder  in  somewhat  the  same  way  as  Marey's 
instrument.      (Figs.  91  and  102.) 

7 


82  THERAPEUTICS    OF   THE    CIRCULATION 

Systolic  and  Diastolic  Pressures. — The  point  of  maximum 
oscillation  indicates  the  diastolic  pressure,  the  point  of  ob- 
literation indicates  the  highest  systolic  pressure,  and  I  find  the 
relation  which  these  bear  to  one  another  is  usually  as  4  to  5, 
or  80  to  100,  though  sometimes  as  4  to  6. 

The  systolic  pressure  shows  the  maximum  height  to  which 
the  blood  pressure  is  raised  by  the  wave  of  blood  driven  into 
the  aorta  by  the  contraction  of  the  left  ventricle.  It  thus 
indicates  in  a  general  way  the  strength  of  the  ventricle.  The 
diastolic  pressure  shows  the  minimum  to  which  the  blood 
pressure  sinks  during  the  interval  when  no  blood  is  coming 
into  the  aorta  from  the  heart  and  the  arterial  system  is  empty- 
ing itself  through  the  capillaries  into  the  veins.  It  therefore 
indicates  generally  the  degree  of  contraction  or  relaxation  of 
the  capillaries.  A  glance  at  Figs.  182  (pp.  155-157)  to  186, 
which  are  reproductions  of  tracings  taken  with  a  mercurial 
kymograph  from  the  carotid  arteries  of  dogs,  will  show  at  once 
how  greatly  the  relation  between  the  systolic  and  diastolic 
pressures  and  the  relation  of  both  of  them  to  the  general 
blood  pressure  may  differ  under  different  circumstances.  Thus, 
in  Fig.  183,  the  systolic  maximum  is  94  and  the  diastolic 
minimum  is  54,  or,  roughly,  as  5  to  2.  In  Fig.  184  the  sys- 
tolic maximum  is  100  and  the  diastolic  minimum  62,  or, 
roughly,  as  5  to  3.  In  Fig.  185  the  systolic  is  106  and  the 
diastolic  78,  or,  roughly,  as  5  to  4.  The  great  oscillation  in 
Fig.  182  may  be  partly  due  to  inertia  of  the  mercurial  column 
(cf.  Fig.  73),  but  only  to  a  slight  extent.  In  Fig.  185  the 
normal  systolic  is  to  the  diastolic  pressure  as  5  to  4,  but  after 
stoppage  of  the  heart  by  irritation  of  the  vagus  it  is  nearly  as 
3  to  i. 

Standardization  of  Instruments. — As  an  aneroid  manom- 
eter is  apt  to  become  altered  by  use,  it  is  well  to  compare  it 
frequently  with  a  mercurial  one,  and  this  can  be  done  in  less 
than  five  minutes,  by  connecting  both  by  means  of  a  T-piece 
with  a  spray-pump,  raising  the  tension  by  5  mm.  at  a  time, 
and  noting  the  correspondence  or  difference  in  the  readings  of 
the  two  instruments.  (Fig.  103.) 


SIZE   OF  VESSELS PRESSURE   IN    VEINS  83 

Size  of  Vessels. — A  most  ingenious  instrument  for  measur- 
ing the  size  of  the  arteries  has  been  devised  by  Dr.  Oliver,  and 
is  called  by  him  the  arteriometer. 

Measurement  of  Pressure  in  the  Veins. — This  may  be 
done  by  choosing  any  convenient  portion  of  a  subcutaneous 
vein  and  pressing  an  instrument  such  as  Figs.  78,  85,  87,  or 


FIG.  103.  Author's  apparatus  for  ascertaining  the  correctness  or  amount  of  error 
in  an  aneroid  sphygmomanometer.  By  means  of  a  three-way  stopcock  both  the  aneroid 
and  a  mercurial  manometer  are  put  into  communication  with  a  pressure  bulb  of  a 
spray  apparatus.  The  pressure  is  then  raised  50  mm.  at  a  time,  and  the  readings  of 
the  mercurial  and  aneroid  compared  at  each  pressure. 

88  upon  its  distal  end  with  sufficient  force  to  stop  the  flow  of 
blood.  The  proximal  part  is  then  emptied  of  blood  by  pressing 
the  tip  of  a  finger  along  it.  The  pressure  of  the  pad  or  bulb 
is  then  relaxed,  and  the  pressure  noted  at  which  the  vein 
again  fills. 


84  THERAPEUTICS    OF    THE    CIRCULATION 

A  simple  way  of  roughly  estimating  the  venous  pressure  is 
to  notice  at  what  height  above  the  level  of  the  heart  the  veins 
of  the  hand  become  empty.  Normally,  they  should  do  so 
about  the  level  of  the  third  rib,  or  a  little  above.  The  greater 
the  venous  pressure  the  higher  must  the  hand  be  raised. 

Measurement  of  Pressure  in  the  Capillaries. — The  method 
of  doing  this  we  owe  to  Ludwig  (N.  v.  Kries,  "  Ludwig's 
Arbeiten,"  1875,  p.  69).  It  consists  on  laying  in  the  skin  a 
piece  of  glass  of  a  definite  size,  which  can  be  pressed  down 
with  more  or  less  force,  and  noting  the  lowest  pressure  at 
which  the  skin  becomes  white.  The  pressure  can  be  applied 
by  a  weight  or  by  a  spring.  (Fig.  80.)  The  pressure  may 
be  measured  anywhere,  but  the  back  of  a  finger  or  the  lobe  of 
the  ear  is  most  suitable.  The  pressure  varies  with  the  height 
at  which  the  hand  is  held.  When  level  with  the  top  of  the 
head,  it  is  about  24  mm.  of  mercury  (328  of  water)  :  8  inches 


I  CU 


FIG.  104.  Marey's  tambour  for  recording  movements.  It  is  a  metal  ring  which 
slides  on  an  upright  rod,  and  can  be  fixed  at  any  height  by  the  screw  B.  C  is  the 
tube  through  which  the  air  from  the  receiving  instrument  (sphygmograph,  cardiograph, 
etc.)  communicates  with  that  inside  the  tambour  and  causes  the  cover  E  to  rise  or 
fall.  Into  £  a  long  straw  is  fastened  bearing  a  point  which  records  its  movements 
on  a  cylinder. 

below  this,  28  mm.   (397  of  water).     In  the  ear  it  is  about 
20  mm.  of  mercury  (272  mm.  of  water). 

Cardiograph  and  Sphygmograph. — All  the  instruments  I 
have  hitherto  described  have  been  chiefly  for  measuring  the 
amount  of  blood  pressure,  or  the  size  of  the  artery,  but  they  do 
not  give  us  any  indication  of  the  mode  of  contraction  of  the 
heart  or  the  nature  of  the  pulse-wave.  These  have  chiefly 
been  worked  out  by  instruments  devised  by  the  late  Professor 
Marey,  and  the  principle  upon  which  most  of  them  depend  is 


INTRACARDIAC    PRESSURE 


that  of  the  transmission  of  motion  by  air  from  one  elastic 
vessel  to  another.    The  recording  vessel  consists  of  a  shallow 


FIG.  105.  Cardiac  sounds  by  which  the  tracings,  Fig.  108,  were  obtained.  V  is 
a  bulb  which  is  introduced  into  the  right  ventricle,  and  communicates  by  a  tube,  TV, 
with  a  tambour  (Fig.  104).  O  is  another  bulb,  which  is  placed  in  the  auricle,  and 
communicates  by  a  tube,  TO,  with  another  tambour.  These  tambours  register  the 
intra-ventricular  and  intra-auricular  pressures.  af  is  a  sound  for  the  left  ventricle, 
communicating  with  a  tambour  by  the  tube  g. 


86 


THERAPEUTICS    OF    THE    CIRCULATION 


metal  dish  covered  at  the  top  by  a  piece  of  thin  india-rubber. 
Over  this  rests  a  light  lever,  and  the  movements  of  the  rubber 
are  thus  greatly  amplified,  are  rendered  visible  to  the  eye,  and 
can  also  be  recorded  on  a  revolving  cylinder.  The  elastic  ves- 
sel by  which  the  movements  are  received  varies  in  shape  ac- 
cording to  the  purpose  it  is  required  to  serve.  For  the  heart 
it  is  a  long  metal  bulb  with  openings  in  its  sides  over  which 
the  thin  india-rubber  is  tied  (Fig.  105).  For  the  apex  beat 
it  may  be  simply  a  tambour  with  a  spring  to  press  it  against 
the  chest  wall  (Figs.  106  and  107),  and  for  the  pulse  a  tam- 


FIG.    1 06.       Marey's   cardiograph. 


MBb_- 

FIG.    107.      Burden-Sanderson's  cardiograph  for  the 
apex  beat. 


bour  with  a  spring  attached,  which  rests  upon  the  pulse  and 
transmits  its  movements  to  the  receiving  tambour  (Fig.  122). 
The  air  within  this  is,  of  course,  alternately  condensed  and 
rarefied,  and  each  movement  is  faithfully  transmitted  to  the 
recording  tambour  (Fig.  104).  By  introducing  one  of  the 
elongated  bulbs  just  mentioned  through  the  aortic  valves  into 
the  ventricle,  Marey  obtained  tracings  of  the  changes  in  pres- 
sure throughout  the  ventricular  cycle,  as  shown  in  Fig.  108. 
There  is  first  a  slight  rise,  due  to  the  auricular  contraction, 
then  a  sudden  rise,  which  becomes  somewhat  slower  as  it 
increases.  At  the  top  of  this  is  a  plateau  showing  several 


VENTRICULAR    AND    AORTIC    PRESSURE 


oscillations,  then  a  sudden  descent,  marked  at  its  end  by  a  little 
wave,  and  then  an  almost  level  line,  after  which  the  same  se- 
quence again  occurs.  The  alteration  in  rapidity  of  ascent 
which  takes  place  about  the  middle  of  the  systole  probably  indi- 
cates the  time  at  which  the  auriculo-ventricular  valves  become 
screwed  together,  and  the  aortic  valves  are  forced  open  by 
the  increasing  pressure  behind.  The  oscillations  which  occur 
on  the  plateau,  according  to  Marey,  do  not  indicate  mere  vi- 
brations of  the  auriculo-ventricular  valves,  but  real  oscilla- 
tions in  them  and  in  the  blood  on  both  sides  of  them.  The 
sharp  fall  indicates  the  diastolic  relaxation  of  the  ventricle, 


r 


i. 


FIG.  108.  Tracings  of  the  ventricular  systole  (i)  and  of  the  aortic  pulse  (2).  In 
the  first  tracing  a  manometric  sound  was  placed  in  the  left  ventricle;  after  two  beats 
it  was  withdrawn  at  a  from  the  auricle  into  the  aorta.  The  second  tracing  is  ob- 
tained from  a  manometric  sound  placed  permanently  in  the  aorta.  The  part  be  and 
&'</  is  common  both  to  the  ventricular  and  aortic  tracing.  At  this  point  the  aortic 
valves  are  open  and  the  ventricle  and  aorta  are  in  free  communication;  V  in  the 
second  tracing  marks  the  point  where  the  blood  begins  to  flow  into  the  aorta;  v  marks 
the  point  where  the  mitral  valves  and  v'  where  the  sigmoid  valves  close. 

and  the  little  wave  at  the  end  marks  the  time  of  closure  of  the 
sigmoid  valves. 

When  the  bulb  is  withdrawn  from  the  ventricle  into  the 
aorta,  a  tracing  is  obtained  which  is  almost  exactly  like  that 
of  the  ventricle  with  the  lower  part  of  it  cut  off  and  a  gradual 
descent  substituted  for  the  sudden  fall  (Fig.  108,  i  (a,  b, 
and  c),  and  2). 


88 


THERAPEUTICS    OF   THE    CIRCULATION 


FIG.   109. 


Diagram  to  show  the  analogy  of  the  senile  pulse  to  the  ventricular  beat. 
(After  Marey.) 


FIG.  no.  Sphygmogram  showing  the  effect  of  increased  tension  on  the  pulse. 
The  first  half  was  taken  while  both  femoral  arteries  were  compressed.  The  latter 
half  after  the  tension  had  been  reduced  by  ceasing  the  compression.  (After  Marey.) 


FIG.   in.      Tracing  of  a  normal  pulse. 


FIG.  112.  Shows  three  tracings  of  a  healthy  pulse  with  varying  degrees  of  tension. 
In  i  the  tension  is  high  owing  to  the  contraction  of  the  arterioles  from  cold;  2  and 
3  show  diminished  tension  from  warm  clothing  causing  relaxation  of  the  arterioles. 
(After  Marey.) 


EFFECT    OF    ARTERIES    ON    PULSE    WAVES 


89 


If  the  aorta  were  rigid,  this  form  of  curve  would  be  trans- 
mitted on  to  the  periphery,  and  we  do,  indeed,  find  that  the 


FIG.   113.      Effect  of  fever  on  the  pulse;   i   is  a  tracing  taken  during  fever;   2  is  one 
from  the  same  patient  when  the  fever  was  absent.      (After  Marey.) 

radial  pulse  tracing  shows  the  characters  of  the  aortic  pulse, 
namely,  the  flattened  plateau,  and  slow,  rather  even,  descent 


FIG.  114.  Tracings  of  the  pulse  at  different  stages  of  intermittent  fever:  i,  Pulse 
in  apyrexia;  2,  stage  of  chill;  3  and  4,  hot  and  sweating  stages;  5,  apyrexia;  6,  an- 
other chill. 

whenever  the  elasticity  of  the  arteries  is  impaired  by  athero- 
matous  change,  as  in  old  people  (Fig.  109),  or  by  great  dis- 


9o 


THERAPEUTICS    OF    THE    CIRCULATION 


tension  from  high  arterial  pressure   (Fig.   no),  as  in  cases 
of  Bright's  disease. 

Sphygmograms. — In  ordinary  healthy  people  the  elasticity 
of  the  aorta  and  arterial  walls  is  sufficient  to  modify  the  trac- 
ing very  greatly,  and  in  healthy  people  the  sphygmogram  has 
the  following  characters :  A  fairly  sudden  and  extensive  rise 
followed  by  a  moderately  quick  fall  for  a  certain  distance, 


FIG.  115.     Tracing  from  a  case  of  aortic  regurgitation,  showing  hook  at  top  of  tracing. 

then  a  second  rise  and  then  a  second  slower  fall.  (Fig.  in.) 
Whenever  the  vessels  are  empty,  so  that  the  blood  is  driven 
in  quickly  during  systole,  the  rise  is  sudden.  When  the  ves- 
sels are  full  and  tense,  so  that  the  blood  pressure  within  them 
is  high  and  blood  is  driven  in  slowly,  the  rise  is  slow.  (Fig. 
112,  i ;  114,  i,  2,  and  6.)  The  same  form  of  tracing  may,  to 
a  certain  extent,  also  come  from  the  feeble  heart.  The  arteries 


FIG.    1 1 6.      Tracing  showing  dichrotism. 

may  be  empty  from  aortic  regurgitation,  when  the  blood  flows 
backwards  from  the  heart ;  or  from  capillary  dilatation,  when 
it  flows  rapidly  onwards  into  the  veins.  (Fig.  112,  3;  113, 
i.)  In  the  former  case  the  fall  is,  as  a  rule,  very  sudden 
at  the  commencement,  and  the  movements  are  very  extensive. 
In  the  latter,  the  fall  is  more  gradual.  In  both  cases,  however, 
the  lever  of  the  tambour  may  be  raised  so  suddenly  that  its 


RETARDATION    OF    PULSE 


FIG.    117.       Radial  pulse  before  a   haemorrhage.       (From  Marey,  after  Lorain.) 


FIG.   1 1 8.      Radial  pulse  from  the  same  patient,  after  a  hemorrhage.       (After  Lorain.) 


FIG.  119.  Retardation  of  the  pulse  in  different  arteries.  PV,  curve  o  pres- 
sure in  the  ventricle  of  the  horse.  A,  aortic  pulse.  Ca,  carotid  pulse.  F,  femoral 
pulse.  Each  square  corresponds  horizontally  to  one-tenth  of  a  second.  (After  Marey.) 


92  THERAPEUTICS    OF    THE    CIRCULATION 

own  inertia  carries  it  beyond  the  point  to  which  it  ought  to 
go,  and  a  little  crochet  or  hook  is  formed  at  the  summit  of  the 
tracing.  (Fig.  115.)  A  great  deal  of  trouble  has  been  taken 
to  ascertain  the  exact  cause  of  the  second,  or  dicrotic  wave, 
as  it  is  termed,  on  the  descending  limb  of  the  sphygmograph 
tracing.  (Fig.  116.)  I  shall  not  attempt  to  go  into  this  ques- 
tion here,  but  I  shall  merely  say  that  exaggeration  of  the 
dicrotic  wave  means  increased  power  of  the  heart  in  reference 
to  the  resistance  it  has  to  overcome,  just  as  when  I  take  this 
elastic  ball  and  strike  it  against  the  floor,  it  rebounds  higher 
the  more  force  that  I  use.  When  the  aortic  valves  are  in- 
competent, however,  as  a  rule  we  do  not  get  this  rebound,  and 
the  commonest  cause  of  dicrotism  is  relaxation  of  the  capil- 
laries or  arterioles.  The  most  marked  tracing  of  it  that  I 
ever  obtained  was  from  a  youth  who  had  had  very  profuse 
haemoptysis,  so  that  he  had  become  almost  drained  of  blood. 
(Cf.  Fig.  118.) 

Retardation  of  Pulse-wave. — The  pulse-wave  takes  a 
certain  time  to  travel  from  the  heart  to  the  periphery  (Fig. 
1 1 6),  and  if  the  heart  is  acting  quickly  this  retardation  may 
make  the  radial  pulse  coincide  with  the  cardiac  diastole  rather 


FIG.    1 20.       Marey's   sphygmograph. 

than  the  systole,  and  the  carotid  pulse  should  be  used  and  not 
the  radial  to  fix  the  time  of  cardiac  murmurs. 

Forms  of  Sphygmograph. — There  are  a  number  of  forms 
of  sphygmograph:  Marey's  original  one  (Fig.  120)  ;  Marey's 
as  modified  by  Ludwig  and  Von  Frey;  Marey's  sphygmo- 
graph for  transmission  (Fig.  122),  which  is  very  convenient 


MAREY'S  SPHYGMOGRAPHS 


93 


when  one  wishes  to  get  simultaneous  tracings  of  the  heart, 
radial  pulse,  and  sometimes  also  of  the  large  veins ;  Dudgeon's 


FIG.   121.      Mode  of  applying  Marey's  sphygmograph. 


FIG.    122.       Marey's   transmitting  sphygmograph. 

(Fig.  123),  which,  though  perhaps  less  accurate,  has  come 
much  into  use  on  account  of  its  great  convenience,  readiness  of 
application,  and  portability :  Jacquet's,  which  is  like  Dudgeon's, 


94 


THERAPEUTICS    OF   THE    CIRCULATION 


but  is  provided  with  a  time-marker;  and  Laulanie's,  which- can 
be  used  on  a  finger.     (Fig-.  124.) 

The  sphygmograph  has  given  us  much  useful  information 
regarding  the  circulation,  but  has  not  become  so  extensively 


FIG.    123.      Dudgeon's  sphygmograph. 

used  clinically  as  one  expected  forty  years  ago.  (Vide  Figs. 
204  to  214.)  No  doubt,  this  is  to  a  great  extent  due  to  the 
very  different  tracings  that  are  obtained  according  to  the  mode 
of  application,  although  when  one  is  accustomed  to  use  it 
regularly  the  fallacies  which  would  thus  be  introduced  are 
greatly  lessened,  and  I.  think  it  quite  possible  that  the  sphygmo- 
graph may  again  be  used  more  frequently,  if  employed  in  com- 
bination with  some  instrument  for  estimating  exactly  the 
arterial  tension. 

Nutrition  of  the  Heart. — The  power  of  the  heart  to  con- 
tract quickly  and  powerfully  depends,  like  that  of  the  skeletal 
muscles,  on  its  nutrition,  and  this  is  regulated  to  a  great  extent 
both  by  the  quality  and  quantity  of  blood  it  receives.  The 
heart  is  like  the  priests  of  old,  who  took  the  best  parts  of  the 
offerings  before  the  remainder  was  distributed  to  the  people. 
For  the  coronary  arteries  leave  the  aorta  just  above  the  sig- 
moid  valves,  and  consequently  they  get  the  first  portion  of 
blood  as  it  comes  fully  arterialized  from  the  lungs,  and,  as 
Sir  R.  Douglas  Powell  has  pointed  out,  the  heart  is  thus  almost 
more  dependent  than  other  organs  upon  proper  pulmonary 
aeration. 


CORONARY    ARTERIES 


95 


The  right  coronary  artery  supplies  chiefly  the  right  side  of 
the  heart.  The  left  coronary  artery  supplies  both  the  left 
auricle  and  ventricle  and  also  part  of  the  right  ventricle.  The 
terminal  branches  of  the  two  coronary  arteries  communicate, 


FIG.  124.  Laulanie's  digital  sphygmograph.  E,  disc  on  which  the  pulp  of  the 
finger  rests.  L,  aluminium  lever  which  rests  by  its  projection  H  on  the  root  of  the 
nail.  M  is  a  movable  counterpoise  which  can  be  moved  along  the  rod  J  so  as  to  exert 
on  the  finger  the  proper  amount  of  pressure'  required  to  obtain  the  maximum  oscil- 
lations of  the  lever.  P,  pulley  with  a  writing  point  to  magnify  the  movements  of  the 
lever  L.  G  is  a  rod  terminating  in  a  button  for  taking  the  radial  pulse.  In  doing 
this  the  disc  E  and  the  rod  F  which  carries  it  are  moved  out  of  the  way,  and  a  heavier 
counterpoise  is  employed.  K  is  a  bent  rod  which  permits  of  an  india-rubber  band 
being  employed  instead  of  the  counterpoise.  N  Is  a  milled  head  which  allows  the  rod 
R  to  be  moved  up  and  down  on  the  stem  O,  and  tracings  taken  at  different  heights 
on  a  revolving  cylinder. 


g  THERAPEUTICS    OF    THE    CIRCULATION 

but  not  freely  enough  to  maintain  circulation,  if  one  of  the 
arteries  be  closed,  although  no  doubt  differences  in  this  respect 
exist  in  different  animals,  and  probably  in  different  men. 
When  an  artery  is  closed  very  slowly,  the  communication  with 
the  other  one  may  gradually  become  sufficiently  increased  to 
maintain  the  circulation  after  the  first  has  become  completely 
occluded ;  and  the  vessels  of  Thebesius,  at  least  in  the  dog, 
may  maintain  the  circulation  even  after  both  coronary  vessels 
have  been  obstructed.  In  consequence  of  this,  if  one  artery 
be  ligatured  the  heart  usually  ceases  to  beat,  and  the  same 
occurs  if  an  embolism  should  obstruct  the  artery.  If  one 
artery  be  narrowed  by  atheroma,  that  part  of  the  heart  which 
it  ought  to  nourish  is  apt  to  undergo  fatty  degeneration,  and 
one  can  readily  see  that,  even  if  the  artery  remains  of  its 
proper  size,  it  may  become  relatively  too  small  for  a  heart 
which  has  undergone  hypertrophy. 


FIG.  125.  Diagram  to  illustrate  Bruck's  view  of  the  suction  action  of  the  ven- 
tricular systole  in  drawing  blood  from  the  veins  into  the  auricle.  In  both  figures  p 
is  the  pericardium,  v  the  ventricle,  a  the  auricle,  ao  the  aorta,  and  vc  the  vena  cava. 
For  the  sake  of  simplicity  only  one  auricle  and  ventricle  are  represented. 

Self-massage  of  the  Heart. — In  speaking  of  the  venous 
circulation  in  the  limbs,  I  mentioned  that  the  muscular  move- 
ments tend  to  aid  the  return  of  venous  blood,  and  the  same 
thing  occurs  in  the  heart;  for,  during  the  contraction  of  the 
ventricle,  blood  is  pressed  out  mechanically  from  its  vessels, 
and  during  diastole  the  arteries  are  filled  again  at  high  pres- 
sure with  blood  from  the  aorta.  The  same  thing  probably 
happens  also  with  regard  to  the  lymphatics,  which  run  along- 
side of  the  coronary  arteries. 


SELF-MASSAGE    OF    THE    HEART  97 

As  Briicke  pointed  out  in  one  of  his  lectures,  which  I  heard 
in  Vienna  in  1867,  the  pericardium  may  be  likened  to  a  bell 
jar,  the  walls  of  which  are  more  or  less  rigid,  the  pericardium 
being  attached  to  the  tissues  all  round  it.  (Fig.  125.)  When 


FIG.  126.  Diagram  of  a  transverse  section  of  the  thorax  during  inspiration  and 
cardiac  systole.  It  shows  the  tendency  to  the  formation  of  a  vacuum  in  the  pleural 
and  pericardial  cavities. 

the  ventricle  contracts,  it  tends  to  produce  a  vacuum  in  the 
pericardium,  and  thus  not  only  to  suck  blood  into  the  auricles, 
but  to  exert  suction  upon  the  ventricle  itself,  and  thus  to  draw 


FIG.  127.  Diagram  of  a  transverse  section  of  the  chest  during  expiration  and 
cardiac  diastole,  showing  the  pressure  of  the  walls  of  the  pleural  and  pericardial 
cavities  against  each  other. 

plasma  from  the  blood  vessels  into  the  cardiac  muscle,  and 
also  lymph  into  the  pericardial  space.     When  the  heart  dilates 


98  THERAPEUTICS    OF    THE    CIRCULATION 

again  in  diastole  it  tends  to  press  the  lymph  out  of  the  peri- 
cardium, and  thus  keeps  the  pericardium  always  moist  with- 
out any  accumulation  of  fluid  occurring.  The  alternate  con- 
traction and  dilatation  of  the  heart  thus  keep  up  what  we  may 
term  a  sort  of  self -massage,  by  which  both  the  circulation  of 
blood  and  of  lymph  in  and  around  it  are  properly  maintained. 
(Figs.  126  and  127.)  It  is  evident,  therefore,  from  what  I 
have  just  said,  that  the  maintenance  of  the  heart's  nutrition 
depends  greatly  upon  its  own  activity,  and  this  is  a  point  of 
extreme  practical  importance. 

Nutritive  Action  of  Cardiac  Tonics. — We  can  thus  see 
that,  in  cases  where  the  nutrition  of  the  heart  is  failing,  drugs 


FIG.  128.  After  Ziegler.  Section  of  an  atheromatous  cerebral  artery.  a,  Intima 
considerably  thickened;  b,  bounding  elastic  lamella  of  intima;  c,  media;  d,  adventitia; 
e,  necrosed  denucleated  tissue  with  masses  of  fatty  detritus;  /  and  /,  detritus  with 
cholesterin  tablets;  g,  infiltrated  leucocytes  in  the  intima;  h,  infiltrated  leucocytes 
in  the  adventitia. 

which  stimulate  it  to  increased  action  do  not  act  merely  tem- 
porarily as  cardiac  stimulants,  but  that  they  are  really  at  the 
same  time  cardiac  nutrients.  It  is  because  of  this  fact  that 
the  good  effects  which  we  see  from  the  use  of  strychnine, 
digitalis,  strophanthus,  caffeine,  etc.,  in  cardiac  disease  do  not 


SELF-MASSAGE    OF    THE    ARTERIES  99 

cease  when  the  drugs  are  withdrawn,  but  may  continue  and 
increase,  these  drugs  having  given  a  temporary  increase  to 
the  power  of  the  cardiac  muscle  which  has  enabled  it  to 
nourish  itself  more  efficiently. 

Self-massage  of  the  Arteries. — Now,  a  very  important  set 
of  vessels  in  the  body  are  the  vasa-vasorum,  the  blood-vessels 
which  supply  other  blood-vessels.  When  these  undergo 
change,  so  that  the  blood-vessels  themselves  are  badly  nour- 
ished, the  condition  of  the  circulation  generally  becomes  very 
precarious,  for  there  is  a  great  deal  of  truth  in  the  old  saying 
that  "  a  man  is  as  old  as  his  arteries."  When  his  arteries 
become  atheromatous  (Fig.  128)  or  calcareous,  the  termina- 


i-iG.    129.      Artery  and  vein  in  common   sheath  to  show  the  effect  of  the   arterial 

pulse  in   aiding  venous  circulation.      A,   artery  in   diastole.  V,   distended  vein.       5", 

common  sheath.  A',  artery  distended  by  the  cardiac  systole.  V,  the  vein  compressed 
and  partially  emptied  of  blood. 

tion  of  the  man's  life  is  not  likely  to  be  very  far  off.  But 
the  arteries  also  have  a  power  of  self -massage.  The  hard 
fibrous  tissue  which  forms  their  sheath  usually  envelops  not 
only  the  artery  and  vein,  but  also  the  lymphatics.  Between 
the  intima  and  media  of  the  artery,  and  probably  in  the  media 
itself,  there  are  lymphatic  spaces,  and  in  the  adventitia  there 
are  distinct  lymphatic  vessels.  The  alternate  distension  and 
relaxation  of  the  arterial  wall  at  each  pulsation  not  only  drives 
blood  and  lymph  onwards  towards  the  heart  at  each  beat  of 
the  heart,  but,  during  the  diastole,  as  the  blood  runs  out  of 
the  artery,  there  is  a  tendency  for  the  arterial  coats  to  sepa- 
rate from  one  another,  and  thus  draw  in  fresh  supplies  of 
blood  into  the  vasa-vasorum,  and  of  plasma  from  them  into 
the  arterial  walls.  (Figs.  129  and  162.) 


IOO  THERAPEUTICS  OF  THE  CIRCULATION 

PATHOLOGY  OF  THE  CIRCULATION 

Effect  of  Altered  Quality  of  Blood. — However  good  the 
circulation  may  be  through  the  heart  or  vessels,  they  will 
suffer  if  the  quality  of  the  blood  is  bad.  Thus,  fatty  degen- 
eration of  the  heart  is  found  in  acute  and  chronic  ansemia,  in 
old  age,  in  failing  nutrition  from  disease,  and  from  various 
poisons,  e.  g.,  in  chronic  alcoholism,  or  after  the  administra- 
tion of  chloroform,  arsenic,  or  phosphorus.  But  a  very  fre- 
quent cause  are  the  toxins  which  occur  in  various  diseases, 
especially  those  of  the  infective  fevers.  Sometimes  these 
toxins  instead  of  producing  fatty  degeneration,  cause  a  general 
softening  of  the  muscular  tissue  or  parenchymatous  degenera- 
tion, in  which  the  muscular  cells  become  degenerated  but  not 
fatty. 

Blocking  of  Coronary  Arteries. — Partial  blocking  of  a 
branch  of  the  coronary  artery  may  produce  a  local  necrosis 
of  the  cardiac  wall,  causing  either  sudden  death  or  the  forma- 
tion of  a  fibrous  patch.  When  the  coronary  arteries  undergo 


FIG.  130.  After  Gaskell.  Tracing  showing  stoppage  of  the  heart  by  stimulation 
of  the  vagus.  Aur.  indicates  the  auricular,  and  Vent,  the  ventricular  tracing.  The 
part  included  between  the  upright  lines  indicates  the  time  during  which  the  vagus 
was  stimulated.  C.8  indicates  that  the  secondary  coil  used  for  stimulation  was  eight 
centimeters  distant  from  the  primary.  The  part  of  the  tracing  to  the  left  hand  shows 
the  regular  contraction  of  moderate  height  before  stimulation.  During  stimulation,  and 
for  some  time  after,  the  movements  of  both  auricle  and  ventricle  are  entirely  arrested. 
After  they  again  commence,  they  are  small  at  first,  but  soon  acquire  a  much  greater 
amplitude  than  before  the  application  of  the  stimulus. 

gradual  closure,  the  muscular  tissue  they  supply  either  under- 
goes fibrous  change  or  fatty  degeneration.  In  either  case 
the  heart  is  much  weakened;  and  in  chronic  valvular  disease, 
.and  in  old  people,  brown  atrophy  is  common. 


BLOCKING  OF  CORONARY  ARTERIES 


IOI 


In  the  arteries,  as  in  the  heart,  interference  with  the  blood 
supply  causes  degeneration.  In  one  form — the  nodular  form 
— there  is  inflammation  in  and  around  the  arterial  coats  with 
local  infiltration  about  the  vasa-vasorum,  leading  to  spots  of 
degeneration,  and  formation  of  an  atheromatous  button,  or 
a  patch  of  nodular  arterio-sclerosis.  In  old  people  the  arterial 
walls  become  stiff,  and  are  often  as  rigid  as  pipe-stems  from 
calcareous  deposit,  while  the  tissue  underneath  the  intima  may 
break  up  and  form  rough  atheromatous  ulcers.  One  of  the 
most  important  changes  of  all  is  the  diffuse  arterio-sclerosis, 
or  as  Gull  and  Sutton  call  it,  arterio-capillary  fibrosis,  in 
which  the  wall  becomes  thickened  from  a  deposit  of  hyaline 
tissue  between  the  muscular  and  the  endothelial  coats.  This 
deposit,  which  is  so  liable  to  occur  in  kidney  disease,  is  of 
great  importance,  because  a  lessening  of  the  lumen  of  the 


FIG.   131.      After  Gaskell.      Tracing  showing  diminished  amplitude  and  slowing  of  the 
pulsations  without  complete   stoppage,   during  irritation   of  the  vagus. 

arterioles  increases  the  peripheral  resistance,  leads  to  hyper- 
trophy of  the  heart,  and  thus  to  an  enormous  increase  in  blood 
pressure,  with  consequent  danger  of  rupture  and  apoplexy. 

It  is  evident  that  thickening  of  this  sort  is  not  likely  to 
yield  readily  to  vascular  dilators,  and  that  consequently  one 
may  not  be  able  to  reduce  the  tension  in  a  case  of  gouty  kidney 
by  vascular  relaxants,  such  as  the  nitrites,  to  the  same  extent 
that  one  would  expect  if  the  increased  tension  had  been  de- 
pendent upon  spasm  of  the  muscular  coats  of  the  arterioles 
alone.  It  is  clear,  therefore,  that  more  permanent  good  is  to 
be  hoped  for  from  such  drugs  as  cause  absorption,  and  es- 


IO2  THERAPEUTICS    OF    THE    CIRCULATION 

pecially  from  iodides,  than  from  vascular  dilators  alone.  At 
the  same  time  this  high  tension  either  depends  to  a  certain 
extent  on  muscular  spasm  or  does  not  affect  the  whole  of  the 
vessels  equally,  because  nitrites  will  reduce  the  blood  pressure 
to  a  certain  degree  in  such  cases. 

Effect  of  Feebleness  of  the  Heart  on  the  Nutrition  of 
Bloodvessels. — From  what  I  have  said  regarding  self-mas- 


FIG.  132.  Pulse  tracing,  showing  the  effect  of  massage  and  graduated  movements. 
Each  tracing  is  taken  partly  with  a  slow  and  partly  with  a  quick  movement  of  the 
sphygmograph.  The  upper  shows  high  tension  and  a  feeble  heart;  the  lower  shows 
less  tension  and  a  stronger  heart.  These  tracings  I  owe  to  the  kindness  of  Dr. 
Gustav  Hamel,  to  whose  treatment  I  had  recommended  the  patient. 

sage  of  the  arteries,  veins,  and  lymphatics  within  their  com- 
mon fibrous  sheath,  it  is  evident  that  smallness  of  the  pulse- 
wave  and  imperfect  expansion  of  the  artery  tends  of  itself, 
whether  it  be  due  to  feebleness  of  the  heart,  high  tension,  or 
rigidity  of  the  artery,  to  lessen  the  massage  and  to  interfere 
both  with  the  nutrition  of  the  vessels  and  with  the  onward 
passage  of  venous  blood  and  lymph.  On  the  other  hand,  if 
the  alternate  dilatation  and  contraction  of  the  artery  at-  each 
pulse  be  extensive,  as  in  the  lower  tracing,  Fig.  132,  the  self- 
massage  will  be  well  effected.  Baths,  exercises,  general  mas- 
sage, and  drugs,  which  increase  the  amplitude  of  the  pulse, 
are  therefore  useful  aids  to  the  nutrition  of  the  arteries.  Digi- 
talis and  its  congeners  increase  the  amplitude  of  the  pulse 
by  strengthening  and  slowing  the  heart;  vascular  dilators, 
like  the  nitrites,  do  so  by  diminishing  the  tension. 

Nervous  Depression. — One  of  the  causes  of  feeble  pulse 
is  feebleness  of  the  heart's  action,  and  this  may  be  due  to 
many  causes.  One  common  and  important  cause  is  nervous 


EFFECT    OF    VAGUS    ON    HEART 


103 


FIG.  133. 


After  Gaskell.      Tracing  showing  diminished  amplitude  of  contraction  with- 
out slowing  or  stoppage  during  irritation  of  vagus. 


FIG.  134.  After  Gaskell.  Showing  increased  cardiac  action  from  stimulation 
of  the  vagus.  In  this  figure  the  lower  tracing  is  that  of  the  auricle  and  the  upper 
that  of  the  ventricle. 


FIG.  135.  Showing  the  effect  of  cold  upon  the  arteries.  A  shows  the  normal 
sphygmogram  from  the  radial  artery.  B  is  the  same  after  the  application  of  a  cold 
compress  above  the  elbow.  (After  Winfernitz.) 


IO4  THERAPEUTICS    OF    THE    CIRCULATION 

depression,  which  acts  through  the  vagus  nerve.  This  nerve, 
which  has  received  its  name  of  vagus  from  its  wandering 
course,  and  which  the  Germans  have  translated  as  "  die  her- 
umschweifende  Nerv,"  gives  branches  to  the  heart,  lungs, 
stomach,  intestines,  liver,  and  kidneys.1  As  I  have  already 
mentioned  in  another  paper,  nearly  all  the  emotions  can  be 
expressed  in  terms  of  this  nerve.  We  say  that  the  man's 
heart  sinks  within  him  for  fear  or  apprehension,  it  beats  high 
with  joy  or  hope,  he  sighs  for  grief ;  the  stomach  is  affected, 
and  vomiting  may  ensue  from  disgust ;  the  bowels  move  with 
compassion;  and  the  effect  upon  the  kidneys  from  simple  ex- 
citement is  well  known  to  all  those  who  have  had  to  do  with 
examinations.  Nervous  depression  from  emotional  causes  is, 
I  believe,  a  much  more  potent  factor  in  disease  of  the  circu- 
lation than  is  generally  recognized.  The  effect  of  grief, 
worry,  and  anxiety  upon  the  circulation,  especially  in  elderly 
people,  is  sometimes  very  marked.  Not  long  ago,  I  saw  a 
man  whose  heart  was  very  much  diseased  indeed,  as  shown 
by  physical  examination,  but  he  displayed  wonderfully  few 
symptoms  until  he  was  told  the  actual  condition  of  his  circu- 
lation, when  he  seemed,  to  use  a  common  expression,  "  to 
take  it  to  heart,"  and  from  that  moment  he  went  down  steadily 
and  rapidly,  and  died  within  a  few  days.  The  coincidence 
was  very  marked,  as  the  change  in  him  occurred  within  a 
couple  of  hours,  so  that  one  could  hardly  ascribe  it  to  anything 
else  than  nervous  depression.  Conversely,  hope  and  joy  are 
most  potent  factors  in  stimulating  the  cardiac  action,  and  thus 
increasing  the  circulation  throughout  the  body,  and  putting 
into  action  all  those  subsidiary  aids  to  the  nutrition  of  the 
vessels,  and  the  return  of  venous  blood  and  lymph,  of  which  I 
have  already  spoken. 

One  can  plainly  see  that  long-continued  depression  of  the 
heart's  action  by  grief  may  bring  about  a  condition  of  mal- 
nutrition with  no  very  definite  organic  change  to  explain  it; 

1The  pneumogastric  appears  to  exert  its  action  on  the  last  three  organs 
through  the  coeliac,  hepatic,  and  splenic  plexuses. 


FATTY    DEGENERATION  IO5 

and  such  a  condition  is  indeed  frequently  noticed,  not  only 
in  the  old,  but  even  in  the  young,  where  sometimes  it  pro- 
duces a  predisposition  to  tuberculosis.  I  have  seen  one  girl 
who  was  really  murdered  by  a  curate,  although  no  Court  of 
Justice  could  have  laid  the  crime  at  his  door.  He  paid  atten- 
tions to  her,  led  her  to  believe  that  he  was  going  to  marry 
her,  then  suddenly  forsook  her  and  married  another.  Grief 
at  this  action  depressed  the  circulation  of  the  poor  girl  he 
had  deserted,  brought  about  a  condition  of  malnutrition,  she 
got  phthisis,  and  died  in  less  than  a  year. 

It  is  possible  that  an  abnormally  low  blood  pressure  may 
sometimes  be  a  precursor  of  phthisis,  and  give  earjy  warning 
of  danger.  I  have  seen  one  case  in  which  an  abnormally 
low  pressure  was  accidentally  found  in  an  apparently  healthy 
man,  who  developed  phthisis  several  months  afterwards. 

Fatty  Degeneration. — Another  very  frequent  cause  of 
weakened  cardiac  action  is  degeneration  of  the  muscular 
structure  itself,  fibrous  or  fatty.  This  occurs  very  often  in 
diphtheria,  typhoid  fever,  and  other  infective  diseases.  It 
may  also  occur  from  altered  nervous  supply,  and  Eichhorst1 
observed  fatty  degeneration  in  the  heart  of  fowls,  and  Was- 
silieff  in  that  of  rabbits,2  after  section  of  the  vagi.  Probably 
the  great  weakness  of  the  heart  after  diphtheria  is  due  in 
some  cases  to  a  double  action,  viz.,  (i)  to  the  effect  of  the 
toxin  in  causing  degeneration  of  the  cardiac  muscles,  and  (2) 
to  its  effect  in  producing  paralysis  of  the  vagus  nerves,  just 
as  it  does  of  the  nerves  going  .to  the  pharynx.  This  paralysis 
is  shown  by  the  extreme  rapidity  of  the  pulse,  which  may 
come  on  during  the  height  of  the  disease  and  continue  for 
months  afterwards. 

Fatty  or  fibrous  .degeneration  of  the  muscular  fibers  nat- 
urally produces  feeble  action  of  the  heart,  and  such  degenera- 
tion is  commonly  consequent  upon  interference  with  the  circu- 

1  Eichhorst,  Die  trophischen    Besiehungen  der  Nervi    Vagi   sum  Herz- 
muskel,  Berlin,  1879,  p.  18. 
-  Wassilieff,  Ztsch.  f.  klin.  Med.,  1881,  iii.,  316. 


io6 


THERAPEUTICS    OF    THE    CIRCULATION 


lation  through  the  coronary  arteries.  Here  we  must  distin- 
guish between  the  two  sides  of  the  heart,  because  although 
both  coronary  arteries  may  be  affected,  yet  occasionally  we 
find  one  affected  and  not  the  other.  The  symptoms  due  to 
affection  of  the  two  sides  we  shall  have  to  consider  later  on. 


FIG.  136.      Shows  the  effect  of  warm  clothing  in  dilating  the  arterioles,  quickening  the 
pulse,  and  reducing  the  high  tension  of  i  to  the  low  tension  of  3.      (After  Marey.) 

Pulse-rate. — The  rate  of  the  heart,  the  rapidity  or  infre- 
quency  with  which  it  beats,  depends  upon  many  factors.  In 
healthy  animals  increased  blood  pressure  slows  the  heart  by 
its  action  upon  the  vagus  roots,  but  when  these  nerves  are 
divided  increased  pressure  has  a  variable  action  on  the  heart; 


FIG.   137.      Effect  of  fever. 

sometimes  slowing  it,  sometimes  quickening  it,  but  the  con- 
ditions, upon  which  such  retardation  or  acceleration  depend 
have  not  yet  been  fully  ascertained.  Heat  as  a  rule  acceler- 
ates the  pulse-rate  and  cold  retards  it,  the  effect  of  heat  being 
to  fender  the  heart  more  excitable,  so  that  (i)  stimuli  are 
generated  more  quickly  in  the  venous  sinus  and  auricles,  and 


PULSE-RATE EXOPHTHALMIC    GOITRE  IO/ 

(2)  also  pass  more  quickly  to  the  ventricle.  The  effect  of 
cold  on  the  isolated  heart  is  exactly  the  opposite.  Moreover, 
heat  tends  to  dilate  the  vessels,  and  thus  to  lessen  the  resis- 
tance the  heart  has  to  overcome,  while  cold  has  an  opposite 
effect.  The  circulation  in  fevers,  therefore,  is  usually  rapid, 
and  a  warm  room  sometimes  appears  to  cause  such  vascular 
dilatation  that  in  delicate  people  faintness  comes  on  and  a 
tendency  to  syncope;  the  dilatation  probably  occurring-  chiefly 
in  the  splanchnic  area,  in  which  the  blood  accumulates,  as  it 
does  after  section  of  the  splanchnics.  (Cf.  Fig1.  10,  p.  12.) 

The  normal  pulse-rate  in  men  is  from  about  60  to  80  per 
minute.  Its  rate  when  the  vagi  are  paralyzed  is  about  120. 
This  is  known  from  the  fact  that  large  doses  of  atropine  or 
belladonna  paralyze  the  vagus;  and  in  cases  of  poisoning  by 
these  substances  in  man  the  pulse-rate  has  gone  up  to  120  or 
upwards.1  In  very  nervous  people,  especially  some  women, 
the  pulse-rate  may  rise  a  good  deal  above  this,  but  such  quick- 
ening is  only  temporary. 

The  pulse  of  120  occurs  very  frequently  as  a  temporary  con- 
dition in  fever,  and  may  occur  more  or  less  permanently  from 
paralysis  of  the  vagi  after  diphtheria,  or  from  alcoholic 
neuritis. 

Exophthalmic  Goitre. — In  cases  of  exophthalmic  goitre 
the  internal  secretion  of  the  thyroid  appears  not  only  to  quicken 
the  heart  but  to  dilate  the  vessels,  and  in  this  disease  the  pulse 
frequently  rises  to  130  or  140  beats  per  minute,  or  even  more. 
It  would  thus  appear  that  not  only  is  the  vagus  paralyzed,  but 
that  the  accelerators  are  stimulated.  That  this  effect  upon  the 
circulation  is  partly  though  not  entirely  due  to  the  action  of 
the  actual  secretion  of  the  gland  itself,  is  shown  by  the  fact 
that  thyroid,  when  taken  by  the  mouth  too  frequently  and 
too  long,  is  cases  of  myxcedema,  will  produce  these  effects 
upon  the  circulation. 

1  Atropine  probably  stimulates  the  accelerators  as  well  as  paralyzes  the 
inhibitory  nerves  of  the  heart. 


LECTURE  IV 

Paroxysmal  Tachycardia — Bradycardia — Intermittent  Pulse — Palpitation 
— Shock — Syncope — Embolism  and  Thrombosis — Claudication — Angina 
Pectoris — Raynaud's  Disease — Chilblains,  Urticaria,  Angio-neurotic  (Ede- 
ma— Migraine — Sensitiveness  of  Arteries — Sensitiveness  of  the  Heart — 
Valvular  Diseases  of  the  Heart — Aortic  Obstruction — Aortic  Regurgita- 
tion — Failing  Compensation — Mitral  Incompetence  (Functional). 

Paroxysmal  Tachycardia. — There  is  a  nervous  affection 
of  the  heart  known  as  paroxysmal  tachycardia,  in  which  the 
pulse  suddenly  becomes  quick  and  continues  so  for  a  length 
of  time,  varying  from  minutes  to  hours,  and  then  returns  sud- 
denly to  the  normal.  It  is  usually  accompanied  by  feelings 
of  great  discomfort,  sometimes  like  those  of  angina  pectoris. 
The  cause  of  it  is  obscure.  It  is  generally  associated  with 
some  disease  of  the  walls  of  the  heart,  especially  with  fatty 
degeneration. 

Bradycardia. — Another  condition,  just  the  opposite  of  this, 
is  extreme  slowness  of  the  heart,  or  bradycardia.  In  this 
condition  the  pulse  may  fall  as  low  as  eighteen  per  minute. 
Napoleon's  pulse  is  said  to  have  been  only  forty  per  minute 
during  the  whole  of  his  life.  The  slow  pulse  may  be  either 
apparent  or  real.  In  some  cases  an  apparent  slowness  is  due  to 
the  fact  that  some  beats  of  the  heart  are  so  feeble  that  the 
ventricle  never  opens  the  aortic  valves,  and  no  pulse  reaches 
the  wrist.  Sometimes  alternate  beats  are  weak  and  strong,  so 
that  for  a  heart  beating  eighty  times  per  minute  only  forty 
radial  pulses  are  felt.  (Fig.  138.)  In  other  cases,  however, 
there  are  no  small  beats  but  only  slow  pulsations.  Weakness 
of  the  heart  leading  to  this  condition  may  occur  from  tempo- 
rary feebleness  after  fevers,  and  especially  infective  fevers 
such  as  diphtheria,  enteric,  pneumonia,  and  rheumatic  fever, 
or  from  general  debility,  or  from  fatty  or  fibroid  degeneration 
of  the  cardiac  walls.  It  sometimes  occurs  when  the  resistance 

1 08 


SLOW    PULSE INTERMITTENT    PULSE  ICK) 

which  the  left  ventricle  has  to  overcome  is  very  great,  as  in 
Bright's  disease  and  lead  poisoning.  It  also  may  happen  from 
increased  resistance  to  the  action  of  the  right  ventricle  in  em- 
physema. It  may  be  due  to  irritation  of  the  vagus  center  in 
the  medulla,  either  by  (i)  central  influence,  or  by  (2)  reflex 
stimulation  of  peripheral  origin.  Among  the  central  causes 


FIG.  138.  Tracings  from  the  left  ventricle  and  aorta  showing  a  slow  pulse  in  the 
aorta  due  to  each  alternate  beat  of  the  ventricle  being  too  weak  to  overcome  the 
pressure  within  the  aorta  and  left  the  aortic  valves.  The  upper  tracing,  VG,  is  from 
the  left  ventricle.  The  lower,  A,  is  from  the  aorta.  N  is  the  level  which  the  pres- 
sure within  the  ventricle  must  attain  in  order  to  raise  the  aortic  valves.  (After 
Marey.) 

are  pressure  upon  the  brain  by  tumor;  by  effusion  of  blood, 
as  in  apoplexy;  by  chronic  inflammation,  as  in  general  paral- 
ysis; as  well  as  in  mental  affections,  mania,  and  melancholia, 
and  disease  or  injuries  of  the  medulla  itself,  and  of  the  cervical 
cord.  It  may  be  brought  about  by  reflex  irritation  from  the 
sexual  organs,  from  the  skin,  from  the  liver,  or  from  the 
stomach,  as  in  chronic  dyspepsia,  gastric  ulcer,  and  cancer. 
(Fig.  139.)  It  occurs  in  poisoning  by  bile-acids,  in  jaundice, 
the  action  here  being  probably  exerted  on  the  muscular  fiber. 
Other  agents,  such  as  tobacco,  coffee,  digitalis,  and  sometimes 
alcohol  may  cause  it,  partly  by  their  action  upon  the  cardiac 
muscle,  and  partly  upon  its  nervous  supply. 

Intermittent  Pulse. — Both  in  tachycardia  and  bradycardia, 
although  the  rate  of  the  pulse*  is  disturbed,  its  rhythm  remains 


no 


THERAPEUTICS    OF   THE    CIRCULATION 


regular.  Intermission  of  the  pulse  is  a  frequent  condition. 
In  it  one  beat  is  occasionally  dropped.  This  may  happen  once 
in  three  times,  so  that  two  regular  beats  come  followed  by  a 
pause,  or  it  may  occur  in  four,  five,  or  more  beats  which  are 
quite  regular,  or  it  may  happen  at  irregular  intervals;  for 
example,  once  after  three,  next  time  after  five,  next  after 
seven,  and  then  again  after  two.  Such  irregularity  may  pos- 
sibly be  a  portion  of  a  very  large  recurring  rhythm,  but  in 
most  cases  if  such  a  rhythm  exists  it  is  difficult  or  impossible 


Cerebrum  — 


Larynx £>^> 


Gall  bladder 
Stomach 

Kidney  and  ureter. .yC- 

Intestine 

Uterus  -_ 
Bladder 
Vesical  nerves 


Medulla- 
Spinal  cord. 

Vagus  trunk. 

Thoracic  branches. 

Splanchnics. 
Gall  duct. 

Renal  nerves. 


Mesenteric  nerves. 

Uterine  nerves. 


FIG.   139. 


to  make  it  out.  In  the  case  of  a  man  recovering  from  digi- 
talis poisoning,  I  had  occasion  many  years  ago  to  observe 
the  form  of  irregularity  shown  by  the  pulse.1  At  first  the 
beats  were  very  rapid  with  occasional  slow  ones  interspersed, 

'Lauder   Brunton,   "On   Digitalis,"   etc.,   Inaugural   Thesis,    1866.     Re- 
printed in  Collected  Papers  on  Circulation,  First  Series,  pp.  100  and  101. 


IRREGULAR    PULSE DIGITALIS 


II  I 


then  it  became  slow  with  an  occasional  rapid  beat  or  two,  and 
finally  slow  and  regular.     (Figs.  140  to  144.) 

In  poisoning  by  tobacco  the  irregularity  is  sometimes  very 
extraordinary ;  one  slow,  strong  beat  followed  by  a  number  of 


FIG.    140.       Pulse  tracing  from   a  case  of  poisoning  by  digitalis,   showing  quick  pulse 
with  slow  beats  interposed. 


FIG.   141.       Same  case.      Recovering  from  the  effects  of  the  poison,  and  showing  slow 
pulse  with  occasional  quick  beats. 


FIG.   142.      Same  case.      Slow  pulse,  with  beat  interpolated  at  b. 


FIG.    143.       Same  case.      Pulse  regular,  but  quickened  by  food. 


FIG.   144.      Same  case.      Recovering;  pulse  slow  and  regular. 

very  quick  ones.  This  condition  may  also  occur  quite  apart 
from  tobacco,  and  may  persist  for  many  years  without  really 
affecting  the  patient's  health.  It  is  impossible  to  give,  with 
certainty,  any  explanation  at  present  of  the  exact  cause  of 
these  forms  of  irregularity.  Some  of  them,  such  as  irregular 
bradycardia  or  occasional  intermission  of  a  beat,  are  explained 
by  supposing  that  the  conduction  in  the  muscular  fibers  con- 
necting the  auricle  and  ventricle  is  less  perfect  than  usual,  so 
that  a  block  occurs,  as  in  Gaskell's  experiments.  The  cases 
of  tachycardia  with  an  admixture  of  very  rapid  and  slow  beats, 
are  less  easy  to  explain,  on  the  assumption  that  cardiac  rhythm 
is  entirely  a  function  of  its  muscular  fibers,  and  I  am  inclined 


I  I  2  THERAPEUTICS    OF    THE    CIRCULATION 

to  think  that  the  true  explanation  can  only  be  given  on  the 
assumption  that  the  nervous  system  also  plays  a  part  in  the 
cardiac  rhythm,  and  that  sometimes  the  nervous  and  muscular 
rhythms  interfere  with  one  another.  In  my  first  lecture  I 
mentioned  some  of  my  grounds  for  this  belief,  and  since  it 
was  delivered,  details  of  experiments  by  von  Basch  and  Froh- 
lich  have  been  published  which  tend  to  substantiate  the  ac- 
curacy of  the  views  that  I  then  brought  forward.1 

Palpitation. — Palpitation  of  the  heart  is  a  very  troublesome 
symptom,  and  its  causation  is  very  obscure.  Sometimes  it 
appears  to  be  almost  a  purely  subjective  sensation,  as  the 
patient  has  a  sensation  of  the  heart  beating  strongly,  yet  the 
hand  applied  to  the  apex  beat  does  not  perceive  anything  un- 
usual. In  other  cases  the  force  of  the  apex  beat,  as  felt  by 
the  hand,  is  distinctly  increased.  I  have  noticed  such  an 
increase  take  place  in  animals  poisoned  by  digitalis.  In  my 
thesis  on  the  action  of  this  drug,  I  discussed  the  mechanism  of 
palpitation,  and  arrived  at  the  conclusion  that  it  was  probably 
due  to  increased  power  of  the  heart  in  proportion  to  the  resis- 
tance it  had  to  overcome,  so  that  the  ventricular  contraction 
occurred  rapidly,  and  the  apex  therefore  struck  forcibly  against 
the  chest  wall.2  What  seems  to  confirm  this  opinion  is,  I 
think,  the  fact  that  palpitation  is  frequent  in  states  of  debility, 
but  that  when  the  heart  is  hypertrophied  and  the  tension  is 
high,  so  that,  despite  its  abnormal  strength,  the  heart  cannot 
contract  quickly,  palpitation  is  frequently,  indeed  one  may  say 
generally,  absent. 

Effect  of  Position  on  Palpitation. — One  would  naturally 
expect  that  a  constantly  recurring  rhythmic  blow  upon  the 
heart  at  each  pulsation  would  increase  its  action,  and,  as  a 
matter  of  fact,  this  appears  to  be  the  case.  The  heart  is  a 
mobile  organ  and  moves  considerably  to  the  left  when  a  person 
lies  on  that  side.  The  apex,  therefore,  tends  to  strike  more 

^on  Basch  and  A.  Frohlich,  Centralbldtt  f.  Physiologie,  Bd.  xviii. ; 
Litcratur,  1904,  p.  693. 

2Lauder  Brunton,  "On  Digitalis,"  etc.,  Collected  Papers  on  Circulation 
and  Respiration,  First  Series,  p.  52.  London:  Macmillan  &  Co. 


SHOCK SYNCOPE  I  I  3 

forcibly  against  the  chest  wall  and  as  the  effect  of  this  is 
similar  to  that  of  a  blow  on  the  heart  at  each  beat,  many  people 
are  unable  to  lie  on  the  left  side  in  consequence  of  the  palpi- 
tation which  then  comes  on. 

Shock. — Another  important  condition  in  which  both  heart 
and  vessels  appear  to  be  affected  is  that  of  shock.  Here  the 
heart  may  become  slow  and  feeble,  but  this  does  not  appear  to 
be  all,  for  the  general  depression  is  out  of  proportion  even  to 
the  feebleness  of  the  heart's  action.  Shock  is  especially  apt 
to  come  on  from  a  blow  upon  the  abdomen,  and  Goltz  in  his 
famous  experiment  showed  that  if  a  frog  be  suspended  in  the 
upright  position  and  its  heart  exposed,  a  blow  upon  the 
intestines  has  a  twofold  action.  It  (i)  stops  the  heart  reflexly 
through  the  vagus;  but  after  this  effect  has  passed  off  (2)  the 
heart  beats  again,  but  is  empty  and  sends  on  no  blood  into  the 
vessels,  because  the  blow  has  caused  dilatation  of  the  ab- 
dominal vessels  and  all  the 
blood  becomes  stored  up  in 
them,  so  that  none  reaches  the 
heart  (Fig.  145).  It  is  not 
improbable  that  a  similar  effect  FIG.  i4S.  Diagra^o  illustrate  Goitz's 
mav  occur  from  irritants  inside  exPe»ments-  a>  Norma;  heart  in  the 

*  upright    position;    b,    heart    in    same    posi- 

tllC     StOinacll     Or     intestine,     be-   tion  after  shock;  c,  heart  as  in  b,  but  in 

,  ,  ....    recumbent  position,   showing  it  full,  so  as 

cause  when  large  quantities  of  to  keep  up  circuiation,  though  the  veins 
alcohol  have  been  swallowed  at  are  sti11  dilated- 
a  draught,  death  has  occurred  almost  instantly,  and  the  mecha- 
nism of  its  production  was  probably  the  same  as  in  Goitz's 
experiment.  Severe  pain  from  irritation  of  nerves  in  other 
parts  of  the  body  may  stop  the  heart,  but  under  ordinary 
circumstances  it  also  causes  contraction  of  the  abdominal  ves- 
sels, and  thus  keeps  up  the  blood  pressure  and  maintains  the 
circulation.  If  the  pain  be  very  excessive,  it  is  quite  possible 
that  an  opposite  effect  may  be  produced,  and  thus  fatal  syn- 
cope may  ensue. 

I   think  also  that   in   surgical   operations   if  anaesthesia   is 
imperfect,   reflex  stoppage  of  the  heart  may  occur  without 
9 


I  14  THERAPEUTICS    OF    THE    CIRCULATION 

reflex  contraction  of  the  vessels,  and  thus  fatal  shock  may  be 
produced,  whilst  perfect  anaesthesia  would  have  abolished  any 
reflex  action  on  the  heart  as  well  as  on  the  vessels,  and  thus 
prevented  any  danger. 

Syncope. — The  remarkable  difference  between  shock  and 


FIG.  146.  To  show  the  contraction  of  the  vessels  produced  during  the  process  of 
multiplying  245  by  15.  S,  Volume  of  left  arm.  A  marks  the  point  at  which  the 
calculation  was  commenced;  after  this  point  the  pressure  falls.  R,  Respiratory  move- 
ment of  chest.  X,  Abscissa.  T,  Time  line;  every  upright  marks  an  interval  of  five 
seconds. 

syncope  is  that  usually  in  shock  the  brain  remains  clear,  but 
in  syncope  the  person  becomes  suddenly  unconscious.  The 
pathology  of  syncope  has  not  been  thoroughly  made  out,  but 
it  appears  to  be  due  to  sudden  anaemia  of  the  brain.  The 
brain  requires  a  large  supply  of  blood  when  it  is  functionally 
active,  so  that  blood  is  withdrawn  from  the  limbs,  and  they 


FIG.  147.      Tracing  from  the  brain.      A,  In  upright  posture;  B,  with  the  head 
inclined  forwards. 

become  smaller.  This  is  shown  by  Mosso  with  the  aid  of 
the  plethysmograph  (p.  69).  When  measured  by  this  instru- 
ment, the  volume  of  the  arm  was  found  to  become  much 
smaller  when  the  person  thought  hard,  as  the  blood  required 
by  the  increased  functional  activity  of  the  brain  was  with- 
drawn from  the  arm.  (Fig.  146.)  When  the  body  is  up- 


EMBOLISM THROMBOSIS  I  I  5 

right,  the  pressure  of  blood  in  the  brain  is  less,  but  it  becomes 
greater  when  the  head  is  lowered.  (Fig.  147.)  The  recum- 
bent position  is  therefore  the  best  to  restore  a  fainting  person, 
and  the  tendency  to  faint  may  sometimes  be  averted  by  plac- 
ing the  head  on  the  hands  between  the  knees.  (Fig.  148.) 
Before  the  introduction  of  anaesthetics  it  was  a  frequent 
custom  to  perform  operations  in  a  state  of  syncope,  which 
was  induced  by  laying  the  patient  flat  on  the  ground  for  a 
short  time  and  then  raising  him  very  suddenly  to  the  upright 
position  by  several  strong  men.  A  curious  observation  was 
made  by  John  Hunter  on  the  flow  of  blood  during  syncope. 
In  a  lady  who  was  being  bled,  the 
blood  issued  from  the  vein  slowly  and 
was  black,  but  the  moment  she  fainted 
the  blood  rushed  out  quickly  and  be- 
came of  a  bright  color.  This  phe- 
nomenon is  exactly  what  is  seen  in  the 
condition  of  the  submaxillary  gland 
when  its  arterioles  dilate  on  irritation 

FIG.    148.       Attitude  to   pre- 

of  the  chorda  tympani.     As  the  blood  vent  fainting, 

from  the  veins  at  the  bend  of  the  arm 

comes  to  a  great  extent  through  the  muscles,  we  are,  I  think, 
justified  in  believing  that,  in  some  cases  of  syncope  at  least, 
the  vessels  of  the  muscles  undergo  sudden  dilatation,  and  thus 
the  blood  pressure  becomes  enormously  and  instantly  reduced. 
Embolism  and  Thrombosis. — When  the  blood-vessels  be- 
come obliterated,  the  supply  of  blood  to  the  parts  to  which 
they  are  distributed  may  become  so  insufficient  that  the  tissues 
die  and  gangrene  ensues.  This  obliteration  may  be  due  to 
embolism  or  thrombosis ;  as,  for  example,  when  a  clot  or  vege- 
tation becomes  detached  from  the  heart  and  is  carried  onwards 
by  the  circulation  until  it  is  stopped  in  an  artery  through  which 
it  cannot  pass,  and  which  it  consequently  plugs.  Sometimes 
the  arterial  wall  undergoes  atheromatous  degeneration,  and 
this  may  either  lead  to  thrombosis  occurring  at  the  spot  where 
the  wall  is  narrowed,  or  the  atheromatous  matter  may  become 


Il6  THERAPEUTICS    OF    THE    CIRCULATION 

dislodged  and  produce  embolism  further  on.  In  old  persons, 
the  arterial  walls  may  become  degenerated  and  contracted  to 
such  an  extent  that  senile  gangrene  of  the  extremities  appears. 
Before  such  a  stage  as  this  is  reached,  however,  an  inability  for 
exertion  comes  on.  This  was  noticed  by  Sir  Benjamin  Brodie, 
and  his  description  is  so  good  that  I  cannot  do  better  than 
quote  it : 

Claudication. — "  Such  patients,"  he  said,  "  walk  a  short 
distance  very  well,  but  when  they  attempt  more  than  this,  the 
muscles  seem  to  be  unequal  to  the  task,  and  they  can  walk  no 
further.  The  muscles  are  not  absolutely  paralyzed,  but  in  a 
stage  approaching  to  it.  The  cause  of  all  this  is  sufficiently 
obvious.  The  lower  limbs  require  sometimes  a  larger  and 
sometimes  a  smaller  supply  of  blood.  During  exercise  a  larger 
supply  is  wanted  on  account  of  the  increased  action  of  the 
muscles :  but,  the  arteries  being  ossified  or  obliterated  and  thus 
incapable  of  dilatation,  the  increased  supply  cannot  be  ob- 
tained." 

Angina  Pectoris. — "  This  state  of  things  is  not  peculiar  to 
the  lower  limbs.  Wherever  muscular  structures  exist,  the  same 
cause  will  produce  the  same  effect.  Dr.  Jenner  first,  and  Dr. 
Parry,  of  Bath,  afterwards,  published  observations  which  were 
supposed  to  prove  that  the  disease  which  is  usually  called 
'  angina  pectoris '  depends  on  ossification  of  the  coronary 
arteries.  .  .  .  When  the  coronary  arteries  are  in  this  condi- 
tion they  may  be  capable  of  admitting  a  moderate  supply  of 
blood  to  the  muscular  structure  of  the  heart;  and  as  long  as 
the  patient  makes  no  abnormal  exertion,  the  circulation  goes 
on  well  enough;  when,  however,  the  heart  is  excited  to  in- 
creased action,  whether  it  be  during  a  fit  of  passion,  or  in 
running,  or  walking  upstairs  or  lifting  weights,  then  the  ossi- 
fied arteries  being  incapable  of  expanding  so  as  to  let  in  the 
additional  quantity  of  blood,  which,  under  these  circumstances, 
is  required,  its  action  stops  and  syncope  ensues ;  and  I  say 
that  this  exactly  corresponds  to  the  sense  of  weakness  and 


RAYNAUD'S  DISEASE — ANGIO-NEUROTIC  OEDEMA         1 17 

want  of  muscular  power  which  exists  in  persons  who  have 
the  arteries  of  the  legs  obstructed  or  ossified."1 

Raynaud's  Disease. — Temporary  contraction  of  the  artery 
and  anaemia  of  the  tissues  occurs  in  a  disease  described  by 
Raynaud,  and  which  bears  his  name.  In  this  disease  the 
arteries  contract  spasmodically,  and  I  have  seen  first  of  all  the 
tips  of  the  fingers  become  cold,  bloodless,  and  shrunken  like 
the  fingers  of  a  corpse,  and  this  condition  gradually  extended 
up  the  hand  in  the  course  of  five  or  ten  minutes.  Sometimes 
only  one  finger  is  affected,  sometimes  the  whole  hand,  some- 
times the  toes,  the  tips  of  the  ears  or  the  nose,  and  occasionally, 
though  rarely,  the  arms  and  legs.  The  internal  arteries  appear 
also  to  undergo  a  similar  contraction,  especially  those  of  the 
kidneys  and  brain,  because  this  disease  is  frequently  associated 
with  hsemoglobinuria  and  sometimes  with  epileptic  symptoms 
and  transient  hemiplegia.  The  condition  is  very  much  like 
what  occurs  after  immersion  of  a  hand  in  very  cold  water, 
and  just  as  after  the  hand  has  been  withdrawn  it  usually  be- 
comes swollen,  hot  and  red,  so  the  extremities  after  the  spasm 
has  passed  off  in  Raynaud's  disease  become  red  and  hot.  In 
very  cold  days  we  notice  that  the  whiteness  of  the  skin  which 
indicates  both  arterial  and  venous  contraction,  is  succeeded  by 
arterial  contraction  with  venous  dilatation,  so  that  the  surface 
becomes  blue  instead  of  white.  The  same  thing  occurs  in  the 
severer  cases  of  Raynaud's  disease,  and  the  term  of  local  as- 
phyxia has  been  given  to  the  condition.  In  extremely  severe 
cases  the  contraction  has  letd  to  complete  stoppage  of  the  blood 
supply,  and  consequent  gangrene,  like  that  which  occurs  in 
senile  degeneration  of  the  vessels. 

Chilblains,  Urticaria,  Angio-neurotic  CEdema. — A  con- 
dition which  is  very  much  allied  to  this,  but  much  milder,  is 
the  common  one  of  chilblains.  Another  ailment  which  is  very 
troublesome  and  where  there  is  a  local  vascular  dilatation  with 
effusion  of  lymph,  is  urticaria.  The  wheals  characteristic  of 

1  Lectures  on  Pathology  and  Surgery,  by  Sir  Benjamin  Brodie,  London, 
1846,  p.  360. 


u8 


THERAPEUTICS    OF    THE    CIRCULATION 


this  complaint  are  very  much  like  those  which  are  produced  by 
a  stinging  nettle.  They  may  occur  without  visible  cause,  but 
in  some  persons  with  an  irritable  vascular  system  they  may  be 
produced  by  simply  scratching  the  skin,  so  that  the  patient's 
name  may  be  written  on  his  back  with  the  finger-nail.  In 


FIG.  149.  Diagram  of  the  carotid, 
temporal,  and  occipital  arteries  in  the 
normal  state. 


FIG.  150.  Diagram  of  arteries  dur- 
ing migraine,  showing  dilatation  of 
the  carotid  and  spasmodic  contrac- 
tions of  the  temporal  arteries. 


so-called  angio-neurotic  oedema,  instead  of  mere  wheals 
occurring,  the  patient  may  become  affected  by  rapid  and  in- 
tense cedema  over  a  large  portion  of  the  body.  I  have  seen 
in  half  an  hour  one  side  of  the  patient's  face  become  so  much 
swelled  that  the  left  eye  was  almost  closed,  and  the  left  side 
of  the  face  was  like  that  of  a  patient  suffering  from  advanced 
renal  dropsy,  whilst  the  other  side-  of  the  face  remained  per- 
fectly healthy.  The  pathology  of  this  condition  has  not  been 
made  out,  but  the  cause  of  the  trouble  probably  is  that  there 
are  toxic  substances  in  the  blood,  for  urticarial  rashes  are  very 
common  after  the  injection  of  diphtheria  antitoxin,  and  I  have 
seen  universal  oedema,  resembling  that  of  advanced  renal 
dropsy,  brought  on  by  the  injection  of  anti-streptococcic  serum. 
The  one-sided  character  of  the  affection  in  the  case  I  have 
just  mentioned  shows  that  the  nervous  system  is  also  deeply 
concerned  in  the  disease. 


PATHOLOGY    OF    MIGRAINE 


Migraine. — Sensitiveness  of  Arteries. — In  the  conditions 
of  which  I  have  just  been  speaking  the  small  arterioles  and 
capillaries  are  chiefly  affected,  but  arteries  of  moderate  size, 
such  as  the  temporal  artery,  and  even  large  arteries  like  the 
carotid,  may  undergo  very  considerable  alterations  in  their 
caliber,  either  in  the  way  of  contraction  or  dilatation.  A  good 
deal  of  discussion  has  taken  place  in  regard  to  the  pathology 
of  sick  headache  or  migraine.  Du  Bois  Reymond  described 
the  temporal  artery  in  his  own  case  as  being  much  contracted 
during  the  headache,  and  therefore  concluded  this  was  a 
general  condition;  while  others 
have  described  this  artery  as 
widely  dilated  and  throbbing, 
and  have  supposed  this  condition 
to  be  constant.  I  have  unfortu- 
nately had  only  too  many  oppor- 
tunities of  repeating  these  obser- 
vations on  my  own  head,  and  I 
have  found  that,  as  is  often  the 
case,  both  parties  are  right  and 
both  parties  are  wrong;  that  the 
condition  described  by  each 
occurs,  but  that  it  does  not  ex- 
tend to  all  parts  of  the  artery  at 
the  same  time.  Sometimes,  for 
example, during  a  fit  of  migraine 
I  have  found  my  temporal  artery 
widely  dilated  and  throbbing  (Fig.  151),  at  other  times  I  have 
found  it  hard  and  contracted,  like  a  piece  of  whip  cord  (Fig. 
150)  ;  but  when  it  was  dilated,  if  I  followed  it  onward  towards 
the  periphery  I  ascertained  that  the  ascending  temporal  branch 
was  contracted  like  a  bit  of  piano  wire.  (Fig.  151.)  On 
most  occasions,  if  I  followed  the  contracted  temporal  artery 
backwards  towards  the  heart,  I  found  that  the  carotid  on  that 
side  appeared  to  be  as  thick  as  my  thumb,  distended  to  three 
times  its  normal  diameter,  and  pulsating  violently.  The  con- 


FIG.  151.  Diagram  of  arteries  dur- 
ing migraine,  showing  dilatation  of 
the  carotid  and  temporal  arteries,  and 
spasmodic  contraction  of  an  ascend- 
ing frontal  branch  of  the  anterior 
temporal  artery. 


120  THERAPEUTICS    OF    THE    CIRCULATION 

elusion  I  came  to,  therefore,  in  regard  to  the  pathology  of 
migraine,  is  that  there  is  peripheral  contraction  and  central 
dilatation  of  the  arteries.  Arteries  are  sensitive,  as  was  known 
in  the  old  days  before  the  introduction  of  anaesthetics,  because 
patients  complained  of  pain  when  the  arteries  were  ligatured. 
That  the  pain  in  migraine  is  to  a  great  extent  due  to  the 
stretching  action  exerted  on  the  contracted  temporal  artery  by 
the  blood  which  tries  to  pour  into  it  from  the  dilated  carotid, 
is  shown  by  the  fact  that  if  pressure  be  exerted  upon  the  caro- 
tid so  as  to  stop  the  pulse  in  the  temporal  artery,  the  headache 
will  frequently  disappear  instantly.  Unfortunately,  however, 
it  is  almost  impossible  to  compress  the  carotid  without  also 
pressing  upon  the  vagus,  and  the  sense  of  oppression  on  the 
chest  which  this  produces  is  so  great  that  one  is  generally 
obliged  to  stop  the  compression  after  a  few  seconds,  although 
the  moment  the  finger  is  removed  the  pain  in  the  head  comes 
back  with  a  rush  of  peculiar  intensity.  Megrim  is  often  re- 
garded as  a  neuralgic  condition,  but  the  observations  upon  my 
own  head  which  I  have  just  detailed  have  convinced  me  that, 
although  the  vascular  disturbance  which  occurs  in  it,  is  almost 
certainly  due  to  an  altered  action  of  the  vaso-motor  nerves, 
yet  the  pain  is  to  a  great  extent  like  that  of  colic,  where  we  find 
intense  pain  due  to  spasmodic  contraction  of  one  part  of  the 
intestine  with  dilatation  or  distension  of  another. 

Sensitiveness  of  the  Heart. — Like  the  vessels,  the  heart  is 
probably  sensitive  and  capable  of  originating  pain  of  a  most 
intense  character.  Pressure  from  the  outside  is  not  felt,  as 
Harvey  discovered  in  the  case  of  young  Lord  Montgomery,  in 
whom  a  congenital  defect  of  the  sternum  exposed  the  heart. 
But  pressure  from  without,  unless  very  excessive,  does  not 
produce  pain  in  hollow  muscular  organs  such  as  the  stomach, 
intestines,  urinary  bladder,  gall-bladder,  gall-duct,  or  ureter, 
yet  distension  from  within  causes  pain  of  the  most  intense 
character  in  all  of  those  organs.  All  these  are  liable  to  dis- 
comfort without  pain,  and  the  heart,  too,  frequently  feels 


SENSITIVENESS    OF    THE    HEART  121 

discomfort  without  pain.  The  sense  of  oppression  which  is 
felt  from  grief  or  anxiety  is,  I  think,  due  to  the  effect  of  the 
vagus  nerve,  because  I  have  noticed  in  my  own  case  that  grief 
has  produced  a  sensation  of  oppression  in  the  chest  which 
has  persisted  after  the  emotion  which  had  given  rise  to  it  had 
passed  away.  We  know  that  this  feeling  of  oppression  can 
be  produced  by  mechanical  irritation  of  the  vagus;  for  Pro- 
fessor Czermak  had  a  small  exostosis  on  one  of  his  cervical 
vertebrae,  and  by  compressing  his  vagus  between  it  and  his 
finger  he  was  able  to  stop  his  heart,  but  the  pressure  at  the 
same  time  caused  this  feeling  of  oppression  or,  as  he  termed 
it,  "  Beklemmung  "  in  the  chest.1 

In  angina  pectoris  there  are  frequently  two  sensations,  or 
perhaps  even  more:  one  of  intense  oppression,  and  one  of 
extreme  pain.  That  of  extreme  pain  I  am  inclined  to  regard 
as  similar  to  colic  in  the  intestine,  and  as  depending  upon 
spasmodic  contraction  of  the  heart  against  resistance  which  it 
can  not  properly  overcome.  It  is  very  difficult  to  make  obser- 
vations in  angina  pectoris ;  because  when  the  attack  comes  on, 
the  apparatus  for  observation  is  generally  not  at  hand,  and 
even  if  it  is,  one  is  so  much  taken  up  with  trying  to  relieve  the 
patient  that  one  does  not  care  to  trouble  him  with  the  applica- 
tion of  instruments.  In  1866  and  1867  I  had  an  opportunity 
of  making  observations  in  a  case  of  angina  pectoris,  in  which 
the  attacks  occurred  every  night  and  lasted  two  or  three  hours. 
During  the  attack  the  pulse  was  very  rapid  and  the  arterioles 
were  contracted,  as  is  shown  by  the  very  slow  fall  of  the 
arterial  tension  during  the  cardiac  diastole.  But  even  with 
everything  at  hand  I  only  once  succeeded  in  making  one  ob- 
servation, and  that  a  very  imperfect  one,  of  the  commencement 
of  an  attack,  which  showed  that  as  the  pain  came  on  the 

1When  Professor  Czermak  described  this  feeling  he  supposed  that  the 
vagus  was  compressed  between  his  finger  and  an  enlarged  gland,  but  I  was 
informed  by  the  late  Professor  Sharpey  that  what  Czermak  supposed  to  be 
a  gland  was  afterwards  discovered  to  be  an  exostosis  on  one  of  the  cervical 
vertebrae. 


122  THERAPEUTICS    OF    THE    CIRCULATION 

tension  rose.  I  was  able  to  make  numerous  observations  re- 
garding the  end  of  an  attack,  and  found  that  as  the  tension 
fell  the  pain  disappeared.1 

VALVULAR  DISEASES  OF  THE  HEART 

Aortic  Obstruction. — We  may  now  pass  on  to  an  impor- 
tant class  of  cases,  namely,  those  of  valvular  disease  of  the 
heart.  The  aortic  orifice  sometimes  becomes  inflamed  during 
foetal  life,  and  becomes  narrowed  in  consequence,  but  more 
usually  the  aortic  valves  become  either  stiff  with  advancing 
years,  or  vegetations,  frequently  calcareous,  form  on  them  and 
lessen  the  diameter  of  the  orifice. 

We  must  distinguish  carefully  between  "  stenosis "  and 
mere  "  obstruction,"  because  a  small  atheromatous  mass  may 
obstruct  the  orifice  and  give  rise  to  a  loud  systolic  murmur, 
but  yet  may  practically  have  little  or  no  effect  in  lessening 
the  lumen  of  the  vessel,  and  consequently  will  produce  no 
practical  change  in  the  circulation  or  in  the  condition  of  the 
pulse.  In  many  cases,  especially  of  elderly  people,  the  aorta 
becomes  atheromatous  and  rough,  so  that  a  systolic  murmur 
occurs  in  it,  but  unless  the  valves  are  affected,  no  regurgita- 
tion  results.  (Fig.  153.) 

Aortic  Regurgitation. — \Vhen  the  valves  are  diseased,  gen- 
eral incompetency  as  well  as  obstruction  occurs,  and  during  the 
diastole  blood  flows  back  into  the  ventricle  as  well  as  onwards 
towards  the  periphery.  (Fig.  153.)  Slight  degrees  of  pure 
stenosis  have  little  or  no  effect  upon  the  circulation,  but  as  the 
work  which  the  ventricle  has  to  do  in  order  to  expel  the  blood 
is  increased  by  the  resistance  in  front,  it  usually  becomes  hy- 
pertrophied.  As  the  amount  of  blood  it  has  to  send  into  the 

1  Since  these  lectures  were  delivered  I  have  had  an  opportunity  of 
watching  a  case  of  severe  angina  pectoris  daily  for  many  weeks,  and  have 
been  unable  to  satisfy  myself  that  although  rise  of  tension,  quick  pulse,  and 
cardiac  pain  usually  came  on  together,  yet  each  might  occur  separately 
without  the  others.  A  feeling  of  anxiety  often  accompanied  the  pain,  but 
anxiety  might  occur  without  pain,  and  vice  versa. 


AORTIC    REGURGITATION 


I23 


aorta  is  not  more  than  usual,  its  cavity  does  not  increase,  or, 
in  other  words,  does  not  undergo  dilatation.  When  there  is 
regurgitation  as  well  as  stenosis,  blood  pours  into  the  ventricle 
from  both  ends,  from  the  auricle  and  from  the  aorta,  so  that 
the  amount  of  blood  it  is  called  upon  to  hold  is  greater  than 
usual.  Its  cavity  becomes  dilated,  and  at  the  same  time,  in 
order  to  send  this  large  wave  of  blood  onwards,  its  walls  re- 
quire to  be  stronger  than  usual.1  They  become  thicker,  or  in 
other  words,  both  dilatation  and  hypertrophy  occur.  So  long 
as  this  compensatory  hypertro- 
phy is  sufficient  to  enable  the 
ventricle  to  do  its  work,  there 
may  be  no  symptoms  at  all,  and 
I  have  seen  patients  engaged  in 
arduous  physical  labor,  carrying 
heavy  hods  of  bricks  up  ladders 
many  times  a  day,  without  know- 
ing that  there  was  anything  the 
matter  with  them.  Not  infre- 
quently one  may  notice  that  the 
face  has  a  peculiarly  pale,  waxy 
look,  and  the  arteries  show  a 
peculiar  irritability  and  tendency 
to  rhythmical  contraction  which, 
as  I  mentioned  in  my  previous 
lecture,  may  be  easily  demon- 
strated by  drawing  the  finger 
across  the  forehead. 

Failing  Compensation. — But  the  enlarged  heart  requires 
an  extra  supply  of  blood,  and  the  coronary  arteries  may  by 
and  by  become  insufficient  to  supply  this,  and  then  commenc- 
ing cardiac  failure  sets  in.  When  this  is  the  case,  symptoms 
of  defective  supply  of  blood  to  the  brain  occur  (Fig.  10), 
such  as  giddiness,  tendency  to  faint,  or  actual  fainting;  and 
symptoms  also  referable  to  the  heart,  such  as  palpitation, 
cardiac  uneasiness,  or  anginal  pain. 

For  pulse  tracing  of  aortic  regurgitation,  vide  Fig.  115,  p.  90. 


FIG.  152.  Diagram  to  show  the 
usual  position  of  the  murmur  which 
indicates  atheroma  of  the  aorta.  It 
is  generally  heard  best  over  the  right 
half  of  the  sternum,  opposite  the  sec- 
ond rib  or  first  intercostal  space,  but 
it  may  be  lower  down  or  higher  up. 
It  is  sometimes  very  limited,  but  is 
frequently  transmitted  upwards  along 
the  innominate,  while  an  anaemic 
murmur  is  transmitted  usually  hori- 
zontally to  the  left 


124 


THERAPEUTICS    OF   THE    CIRCULATION 


Mitral  Incompetence  (Functional). — So  long  as  the  mi- 
tral valves  remain  competent,  the  symptoms  remain  limited  to 
those  parts  of  the  body  supplied  by  the  aorta.  But  when  the 


Carotid  artery  (full)  • 


Aorta  tense  ... 
Veins  tense  and 
moderately  full  4- 


Blailder  (fall) 


—J- — •  Carotid  artery  (empty). 


Aorta  lax. 

Veins  lax  and  full. 


Bladder  (empty). 


FIG.  153.  Diagram  to  illustrate  the  tendency  to  syncope  in  aortic  regurgitation. 
In  a  the  aortic  valves  are  healthy  and  prevent  regurgitation.  The  carotid  and  its 
branches  are  shown  as  full.  In  b  there  is  aortic  regurgitation,  the  blood  flows  out 
of  the  arterial  system  through  the  capillaries  and  into  the  heart.  The  carotid  and  its 
branches  are  shown  as  empty.  In  c  the  condition  is  the  same  as  in  b,  but  the 
patient  is  supposed  to  be  in  the  recumbent  posture,  and  the  carotid  and  its  branches 
remain  full. 

heart  dilates  so  far  that  the  mitral  valves  no  longer  close  the 
auriculo-ventricular  orifice  and  the  blood  pours  back  into  the 


FIG.  154.  Diagram  of  healthy 
heart  in  diastole.  The  aorta 
is  full  of  blood  under  pressure, 
as  indicated  by  the  shading, 
but  the  ventricle  and  auricle 
are  protected  from  pressure  by 
the  sigmoid  valves. 


FIG.  155.  Diagram  of  a  heart 
with  incompetent  aortic  valves. 
The  ventricle  as  well  as  the 
aorta  is  under  pressure  during 
diastole,  but  the  auricle  is 
protected  by  the  auriculo- 
ventricular  valves. 


FIG.  156.  Diagram  of  a 
heart  with  incompetent 
aortic  and  mitral  valves. 
The  auricle  and  veins,  as 
well  as  the  ventricle  and 
aorta,  are  under  pressure 
constantly. 


left  auricle  and  pulmonary  veins,  symptoms  of  pulmonary  en- 
gorgement develop. 

Incompetency  of  the  mitral  valves  may  be  brought  about 
either  by  the  orifice  becoming  too  large  for  the  valves,  or  the 


MITRAL    INCOMPETENCE 


valves  too  small  for  the  orifice.     It  was  shown  by  Ludwig 
that,   when  the    ventricle    contracts    normally,  the  muscular 


FIG.    157.       After    Dr.    Th.    Schott.       Photograph    by   the    Rontgen    rays,    showing   the 
heart   in    a    healthy   man   before   exertion. 

fibers  around  the  auriculo-ventricular  orifice  lessen  it  to  such 
an  extent  that  even  imperfect  valves  might  close  it;  but  when 


FIG.   158.      After  Dr.  Th.  Schott.      Skiagraph  of  the  heart  of  the  same  man  as  Fig.   157, 
after  violent  exertion,  showing  temporary  dilatation. 

the  heart  is  dilated,  the  orifice  becomes  so  large  that  the  valves 
wrill  not  close  it,  however  healthy  they  may  be. 


126  THERAPEUTICS    OF    THE    CIRCULATION 

Cardiac  Strain. — Such  dilatation  occurs  as  a  sequence  to 
aortic  regurgitation,  but  it  also  occurs  from  violent  strain  in 
healthy  people  (Fig.  158),  and  also  from  cardiac  weakness. 
Indeed  this  happens  not  infrequently  in  cases  of  anaemia  and 
debility,  such  as  occur  after  acute  disease.  We  then  find  that 
a  systolic  murmur,  indicative  of  mitral  regurgitation,  becomes 
very  evident,  but  as  the  heart  gains  power,  the  murmur  com- 
pletely disappears.  One  such  murmur  I  watched  with  great 
interest  in  a  girl,  who  was  able  to  play  lawn  tennis  without 
any  injury  whatever,  but  every  time  that  she  went  to  a  dance, 
the  combination  of  late  hours  and  emotional  excitement  with 
active  exercise  brought  on  a  marked  systolic  murmur. 

Regurgitation  may  also  occur  from  irregular  action  of  the 
musculi  papillares,  as  I  observed  in  some  experiments  which 
I  made  during  the  year  1865  upon  the  action  of  digitalis,  and 
where  I  noticed  a  regurgitant  murmur  occur  in  the  heart  of 
a  dog  which  had  been  poisoned  by  digitalis,  although  post- 
mortem examination  showed  the  heart  to  be  perfectly  healthy.1 
Roy  and  Adami  have  also  described  a  similar  condition. 
When  the  mitral  valves  become  incompetent,  the  reflux  of 
blood  at  each  beat  of  a  powerful  ventricle  tends  to  distend 
the  auricle  and  the  pulmonary  veins  from  which  the  normal 
stimulus  to  ventricular  contraction  ought  to  start,  and  in  con- 
sequence of  this  the  cardiac  rhythm  is  apt  to  be  disturbed, 
and  an  irregular  pulse  will  result.  For  this  reason  the  irregu- 
larity of  the  pulse  is  more  frequent  in  mitral  than  in  any  other 
form  of  cardiac  disease. 

1  Lauder  Brunton,  Collected    Papers    on    Circulation    and    Respiration, 
p.  114. 


LECTURE   V 

Mitral  Regurgitation  (Organic) — Mitral  Obstruction — Cardiac  Dyspnoea 
— Venous  Engorgement — Other  forms  of  Cardiac  Disease — Vicious  Circle 
— Methods  of  Treatment  in  Valvular  Disease — Uses  of  Treatment — Rest 
— Position — Use  of  Massage — Effect  of  Flatulence  on  the  Heart — Use  of 
Drugs  in  Cardiac  Disease — Cardiac  Nutrients — Digitalis  and  its  Congeners 
— Resume  of  the  Action  of  Digitalis. 

Mitral  Regurgitation  (Organic). — Incompetence  of  the 
mitral  valves  occurs  from  distortion  of  the  valves  by  inflam- 
mation, or  by  vegetations  on  their  surfaces  which  prevent  them 
from  closing,  even  more  frequently  than  from  dilatation  of 
the  auriculo-ventricular  orifice.  The  result,  however,  is  the 
same.  Whenever  the  valves  are  incompetent  the  ventricle 
drives  the  blood  at  each  systole  back  into  the  auricle  and  pul- 
monary veins,  as  well  as  forward  into  the  aorta,  and  during 
systole  the  pressure  in  the  auricle  and  in  the  pulmonary  veins 
must  be  nearly,  if  not  quite  so  high,  as  that  in  the  aorta.  In 
consequence  of  this,  the  auricle  becomes  hypertrophied.  As 
there  are  no  valves  in  the  pulmonary  veins,  it  seems  extraordi- 
nary that  the  pulmonary  vessels  do  not  suffer  more  than  they 
do,  and  it  appears  to  me  not  improbable  that  the  contractile 
power  of  the  pulmonary  veins,  which  Sir  Joseph  Fayrer  and  I 
rediscovered,1  may  take  the  strain  off  the  capillaries  in  the 
lungs,  and  thus  prevent,  to  some  extent,  the  tremendous  con- 
gestion that  might  otherwise  take  place. 

Mitral  Obstruction. — When  the  mitral  valves  are  much  in- 
flamed, they  not  unfrequently  become  adherent  to  one  another, 
and  the  mitral  orifice  is  thus  so  much  narrowed  that  sometimes 
it  will  hardly  admit  the  point  of  the  finger.  Great  hypertrophy 
of  the  auricle  then  occurs,  while  the  ventricle  may  be  smaller 
than  normal.  In  such  a  condition  the  pressure  within  the 
pulmonary  veins  and  the  auricle  tends  to  be  more  or  less  con- 

1  Cf.  P.  18. 

127 


128  THERAPEUTICS    OF    THE    CIRCULATION 

stantly  high,  while  that  in  the  ventricle  becomes  low  after  the 
systole  is  over. 

I  mentioned  before,  when  speaking-  of  the  physiology  of  the 
heart,  that  dilatation  of  the  apex  of  the  frog's  heart  by  pres- 
sure from  within  would  act  as  a  stimulus  to  this  portion  of  the 
ventricle,  and  cause  it  to  beat  rhythmically  when  it  would 
otherwise  remain  perfectly  still.  The  application  of  this  con- 
stant pressure  to  the  pulmonary  veins  and  left  auricle,  while  it 
is  absent  from  the  left  ventricle,  naturally  tends  to  disturb  the 
rhythm,  and  consequently  irregularity  of  the  pulse  is  more  fre- 


FIG.    159.      Tracing  of  pulse  from  a  case  of  mitral  incompetence.       (After  Marey.) 

quent  in  mitral  obstruction  than  in  any  other  form  of  cardiac 
disease.1 

Cardiac  Dyspnoea. — Involuntary  muscular  fiber  seems  to 
have  less  power  of  withstanding  strain  when  it  is  constant  than 
when  it  is  intermittent,  and  it  is  in  mitral  obstruction  that  we 
most  frequently  find  the  pulmonary  capillaries  giving  way  be- 
fore the  strain  and  haemoptysis  occurring. 

Backward  pressure  in  the  pulmonary  circulation,  of  course, 
retards  circulation  through  the  lungs;  less  blood  can  pass 
through  in  a  given  time,  and  consequently  both  in  mitral  re- 
gurgitation  and  in  mitral  obstruction,  shortness  of  breath  is 
a  prominent  symptom.  A  patient  may  be  perfectly  comfort- 
able while  at  rest,  but  there  is  no  reserve  power,  and  exertion 

1Luchsinger  (Arch.  f.  d.  ges.  Physiol.,  xxvi.,  p.  451,  1881)  and  Schiff 
(ibid.,  xxvi.,  p.  456)  found  that  the  rhythmical  contraction  in  veins  observed 
by  Wharton  Jones  (Phil.  Trans.,  1852,  p.  i)  depend  on  the  pressure  inside 
the  veins;  being  well  marked  when  the  pressure  is  high,  and  absent  when 
the  pressure  is  low.  Cf.  p.  17,  observations  of  Brunton  and  Fayrer  on 
"Rhythmical  Pulsation  of  the  Vena  Cava  and  Pulmonary  Veins";  for 
if  this  observation  holds  good  for  these  veins,  the  pressure  may  excite 
stimuli  in  the  pulmonary  veins  whose  rhythm  may  still  further  interfere 
with  that  of  the  other  cavities  of  the  heart. 


VENOUS    ENGORGEMENT  I  29 

at  once  brings  on  quickened  breathing  and  distress,  which  may 
sometimes  be  very  severe.  In  consequence  of  this  obstruction 
to  the  pulmonary  circulation,  the  right  ventricle  has  more 
resistance  to  overcome,  it  is  obliged  to  contract  with  more 
force,  and  on  account  of  the  increased  work  tends  to  become 
hypertrophied.  As  a  rule,  its  working  power  becomes  more 
and  more  taxed  until  the  maximum  is  reached,  and  then  it 
begins  to  dilate,  so  that  the  tricuspid  valves  become  incompe- 
tent and  the  blood  pours  back  into  the  auricle  and  the  venae 
cavae. 

Venous  Engorgement. — Dilatation  and  hypertrophy  of 
the  auricle  occur  in  the  same  way  as  on  the  left -side,  but  there 
being  no  valves  in  the  venae  cavae  the  whole  venous  system  is 
likely  to  become  engorged.  The  first  indication  of  venous  en- 
gorgement is  shown  in  those  parts  of  the  body  where  the 
venous  pressure  is  highest,  namely,  in  the  feet  and  ankles, 
because  in  these  places  there  is  not  only  the  backward  pressure 
which  exists  in  the  vena  cava  itself,  but  the  weight  of  the 
column  of  blood  between  the  feet  and  the  heart.  It  is  this 
extra  weight  that  determines  the  yielding  of  the  venous  capil- 
laries and  the  exudation  of  fluid.  This  is  shown  by  the  fact 
that  when  the  weight  of  blood  is  taken  off  the  feet  by  keeping 
them  raised  upon  a  high  stool  or  chair  during  the  day,  or  by 
putting  the  patient  to  bed,  the  oedema  as  a  rule  disappears. 
Next  the  liver  and  portal  system  suffer.  The  liver  becomes 
congested  and  enlarged,  and  flatulence  both  in  the  stomach  and 
intestine  becomes  a  troublesome  symptom.  As  the  congestion 
increases  the  liver  may  be  felt  hard,  smooth,  and  large,  reach- 
ing down  sometimes  to  the  iliac  crest,  and  water  exudes  into 
the  abdominal  cavity,  producing  ascites.  The  kidneys  also 
become  congested.  The  increased  venous  pressure  lessens  the 
circulation  through  the  glomeruli,  the  urine  becomes  scanty 
and  loaded  with  lithates,  and  then  albuminuria  appears. 

Other  Forms  of  Cardiac  Disease. — It  is  obvious  that  all 
the  conditions  I  have  just  described  may  result  as  consequences 
of  aortic  regurgitation,  but  the  number  of  these  conditions  will 

10 


I3O  THERAPEUTICS   OF   THE   CIRCULATION 

be  greater  or  less  in  other  forms  of  cardiac  disease,  according 
to  the  point  in  the  circulation  where  the  lesion 'occurs.  Thus, 
we  may  have  all  the  symptoms  of  venous  engorgement  from 
weakness  of  the  right  ventricle  and  inability  to  drive  the  blood 
through  the  lungs.  This  weakness  may  be  absolute,  due  to 
fatty  degeneration  of  the  cardiac  muscle,  consequent  upon 
atheroma  of  the  right  pulmonary  artery;  or  it  may  be  rela- 
tive, due  to  greater  resistance  to  the  circulation  in  the  lungs 
themselves,  as,  for  example,  in  chronic  bronchitis  and  emphy- 
sema. A  very  instructive  experiment  in  regard  to  this  is  that 
which  goes  by  the  name  of  Valsalva.  If  one  breathes  out 
against  resistance — as,  for  example,  by  closing  the  mouth  and 
nostrils  forcibly,  or,  what  is  even  more  instructive,  by  blowing 
against  the  mercurial  column  in  a  manometer — it  is  found 
that  the  pulse  will  stop  entirely  when  the  pressure  within  the 
lungs  reaches  a  certain  point.  As  a  young  man  I  have  fre- 
quently tried  this,  and  could  stop  my  pulse  completely.  So  far 
as  I  can  recollect,  the  height  to  which  I  raised  the  mercury 
before  this  occurred  was  somewhere  between  six  and  eight 
inches,  but  I  have  not  repeated  the  experiment  for  a  long  time, 
and  do  not  care  to  do  so  now,  because  it  is  not  altogether  with- 
out risk.  In  efforts  of  coughing,  expiration  is,  of  course, 
made  against  raised  pressure  caused  by  the  closure  of  the  false 
vocal  cords,1  which  yield  in  an  explosive  manner  after  the  pres- 
sure has  become  raised  to  a  certain  extent,  and  mucus  is  carried 
out  by  the  forcible  stream  of  air  issuing  from  the  lungs.  In 
violent  coughing,  the  effect  of  raised  pressure  in  the  pulmo- 
nary alveoli  upon  the  pulmonary  circulation  becomes  very  evi- 
dent. The  face  becomes  congested,  and  if  the  coughing  be 
long  continued,  becomes  more  or  less  livid,  and  the  jugular 
veins  stand  out  largely  upon  the  neck.  In  people  who  are 
otherwise  healthy,  the  ventricle  recovers  itself  when  the  cough- 
ing ceases,  but  prolonged  strain,  as  in  chronic  bronchitis  or 
spasmodic  asthma,  tends  to  cause  permanent  dilatation  of  the 
right  side  of  the  heart  with  all  its  attendant  evils. 

1  Brunton  and  Cash,  Journ.  of  Anat.  and  Physiol.,  vol.  xvii.,  1882-83. 


REST    IN    TREATMENT    OF    VALVULAR   DISEASE  13! 

Vicious  Circle. — As  in  many  other  things,  the  conditions  in 
cardiac  disease  form  a  vicious  circle.  The  disordered  circula- 
tion disturbs  the  functions  of  other  organs,  and  these  in  turn 
make  the  circulation  worse.  The  condition,  indeed,  reminds 
one  of  Shakespeare's  lines  in  regard  to  sorrow : 

"  Sorrow's  weight  doth  heavier  grow 
Through  debt  that  bankrupt  sleep   doth  sorrow  owe." 

The  disordered  circulation  interferes  with  the  functions  of 
the  lungs,  liver,  stomach,  intestines,  and  kidneys.  On  account 
of  the  difficulty  of  breathing,  exercise  becomes  impossible,  and 
thus  all  the  accessory  aids  to  circulation  given  by  the  muscles 
and  fasciae  during  movement1  are  done  away  with.  Appetite 
becomes  lessened  and  flatulence  increases;  the  elimination  of 
waste  products  by  the  kidneys  is  interfered  with,  and  distension 
of  the  abdomen  either  by  flatulence  alone  or  by  flatulence  with 
ascites  presses  the  diaphragm  up,  encroaches  upon  the  breath- 
ing space  in  the  lungs,  and  tilts  the  heart  up,  thus  still  further 
increasing  its  difficulties.  In  such  cases  it  is  evident  that  the 
patient  is  bound  to  die,  and  to  die  a  somewhat  painful  death, 
unless  medical  art  can  afford  him  assistance.  It  is  very 
fortunate,  however,  that  in  such  cases  medical  art  can  do  so 
much. 

TREATMENT  OF  VALVULAR  DISEASE 

Uses  of  Treatment. — Rest. — There  is  perhaps  no  kind  of 
disease  in  which  the  results  of  treatment  are  so  striking  and 
so  encouraging  as  in  cardiac  disease.  If  we  can  break  the 
vicious  circle  at  one  point,  we  allow  recovery  to  commence; 
and  one  of  the  most  important  agents,  I  think  I  ought  to  say 
the  most  important  agent,  in  the  physician's  power  is  absolute 
rest.  It  is  very  hard  indeed  to  make  patients  understand  what 
one  means  by  absolute  rest.  They  are  inclined  sometimes  to 
take  the  expression  as  meaning  that  they  shall  stay  in  the 
house,  but  that  they  may  go  up  and  down  stairs  as  often  and 
as  quickly  as  they  please.  Now,  few  people  have  any  idea 
of  the  amount  of  work  involved  in  going  up  stairs.  The 

1  Vide  p.  7. 


132  THERAPEUTICS    OF    THE    CIRCULATION 

weight  of  the  body  is  so  evenly  distributed  upon  the  muscles 
of  the  legs  that  we  hardly  feel  the  exertion  in  health,  but  if  we 
suppose  that  we  had  fixed  upon  the  bannisters  of  the  stairs  on 
the  bedroom  floor  a  strong  pulley  provided  with  rope  and 
basket,  and  that  the  patient  weighing,  let  us  say,  150  Ibs.,  is 
put  into  the  basket  on  the  ground  floor,  and  that  we  had  to 
pull  him  up  by  means  of  the  rope,  we  will  then  understand 
the  number  of  foot-pounds  involved  in  the  amount  of  exer- 
tion required  to  bring  him  from  the  dining-room  floor  to  his 
bedroom.  The  weight  is  the  same  and  the  height  is  the  same 
when  the  patient  is  drawn  up  in  a  basket  and  when  he  walks 
up  himself.  By  putting  the  position  before  a  patient  in  this 
way  I  have  sometimes  succeeded  in  convincing  him  that  the 
work  involved  in  walking  upstairs  was  really  great,  and  more 
than  his  enfeebled  heart  could  stand.  But  it  is  not  merely  in 
walking  upstairs  that  the  heart  has  extra  work  to  do.  Even 
in  getting  into  bed,  work  requires  to  be  done,  and  unfortu- 
nately, as  in  the  case  of  a  patient  whom  I  saw  immediately 
after  giving  my  third  lecture  here,  the  exertion  of  getting  into 
bed  may  prove  fatal. 

Rule  regarding  Rest  for  Patients. — The  advice  I  give  to 
patients  is,  that  they  shall  not  take  one  beat  out  of  their  heart 
that  can  possibly  be  avoided;  that  they  shall  not  do  one  thing 
for  themselves  which  anybody  else  can  do  for  them.  Nobody 
else  can  breathe  for  them,  nobody  else  can  swallow  for  them, 
nobody  can  evacuate  for  them ;  but  with  these  exceptions  every- 
thing else  should  be  done  for  them.  When  they  wish  to  sit 
up  in  bed,  they  should  be  raised  up  by  others ;  when  they  wish 
to  turn,  others  should  move  them ;  when  they  wish  to  evacu- 
ate, a  bed-pan  should  be  placed  under  them.  There  are  certain 
people  who  seem  to  be  unable  to  evacuate  either  the  rectum  or 
bladder  in  the  recumbent  position,  and  for  these  I  am  accus- 
tomed to  recommend  that  a  platform  should  be  made  of 
rough  deal,  of  such  a  height  as  to  raise  a  commode  to  the 
level  of  the  bed,  and  that  the  patient  should  be  slewed  on  to 
it  and  off  it  in  such  a  manner  that  the  pelvis  always  remains 


POSITION    IN    TREATMENT    OF   VALVULAR   DISEASE         133 


in  the  same  plane,  and  is  never  either  raised  or  lowered,  the 
only  change  being  in  the  relative  position  of  the  trunk  and 
limbs. 

Position. — But  here  we  are  met  at  once  with  the  great 
objection  that  in  these  severe  cases  the  patient  cannot  lie  down 
on  account  of  difficulty  in  breathing.  The  cause  of  this  diffi- 
culty of  breathing  while  in  the  recumbent  position  is  prob- 
ably of  twofold  origin.  In  the  first  place,  when  the  patient 
is  supine,  the  contraction  of  the  diaphragm  at  each  inspiration 
has  to  raise  the  abdominal 
viscera  (Fig.  160),  while  in 
the  upright  position  it  has 
only  to  push  them  horizon- 
tally forward.  (Fig.  161.) 
Another  cause,  as  Leonard 
Hill  has  pointed  out,  is  prob- 
ably the  extra  tension  in  the 
right  side  of  the  heart,  which 
occurs  when  the  heart  is 

brought  down  to  a  level  with  the  splanch- 
nic area,  and  the  comparative  ease  which 
occurs  in  the  upright  position  is  due  to  the 
blood  remaining  in  the  abdomen  and 
limbs,  so  that  the  tension  in  the  right  side 
of  the  heart  becomes  less  (cf.  Figs.  10  and 
153).  In  some  cases  the  facts  that  when 
the  legs  are  raised,  the  venous  tension  in 
the  cava  becomes  somewhat  greater  than 
when  they  are  dependent,  and  also  that 
when  the  thighs  are  swollen  there  is  a 
little  extra  pressure  exerted  on  the  abdo- 
FIG.  161.  Diagram  to  men  make  ft  necessary  that  the  patient 

show    the     horizontal    mo- 
tion of  the  abdominal  con-   should  be  allowed  to  sit  and  not  be  con- 
tents  in   the   upright  posi-    fined    to    bed        But    jf    he    is    sftting?    he 

should  be  kept  always  in  the  same  posi- 
tion; he  should  not  get  up  at  all,  and  he  should  have  not  an 


FIG.  160.  To  show  the  lifting  of  the 
abdominal  contents  during  inspiration  in 
the  supine  position. 


134 


THERAPEUTICS    OF    THE    CIRCULATION 


ordinary  chair  but  a  night-stool,  so  that  the  evacuations  may 
be  removed  without  disturbing  him.  Various  beds  have  been 
devised  upon  which  patients  can  lie  comfortably  and  have  their 
bodies  and  limbs  placed  at  any  angle  that  is  desired  without 
any  exertion  whatever  on  the  part  of  the  patient ;  but  although 
these  are  theoretically  very  useful,  they  are  not  so  much  used 
in  practice  as  I  think  they  might  be. 

Use  of  Massage. — It  is  evident  that  when  the  patient  is 
resting  completely,  either  in  bed  or  in  a  chair,  all  the  acces- 
sory means  of  circulation  in  the  limbs  of  which  I  have  already 
spoken  are  absent,  and  not  un frequently  one  finds  that  the 
feeble  circulation  in  the  muscles,  and  the  consequent  accumula- 
tion of  waste  products,  give  rise  to  feelings  of  heaviness  in  the 
limbs,  discomfort,  and  restlessness  which  are  very  trying  to 


FIG.   162.      Diagram  of  artery  and  nerve  in  a  sheath  of  connective  tissue  to  illustrate 
self-massage  of  the  artery  and  nerves.      A,  lymphatics.      B,  sheath.      C,  nerve. 

the  patient.  In  health,  the  arteries  which  run  in  the  same 
sheath  as  the  nerves  exercise  a  kind  of  massage  upon  them  by 
the  alternate  contraction  and  expansion  in  the  same  way  as  on 
the  veins  (Fig.  162),  but  when  the  pulse  is  feeble  the  nerves 


ACTION    OF    MASSAGE 


135 


suffer  in  consequence.1  The  indication  for  treatment  here  is 
to  replace  the  natural  accessories  to  circulation  as  far  as  pos- 
sible by  artificial  ones,  and  this  we  are  able  to  do  to  a  certain 


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X     "I 

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FIG.  163.  Diagram  to  show  the  effect  of  massage  on  the  flow  of  blood  through 
muscle,  a  shows  the  amount  of  blood  in  cubic  centimeters  which  flowed  from  a 
muscular  vein  when  it  was  simply  opened.  b,  During  massage.  c,  After  massage. 
In  VI.  the  rate  of  flow  was  increased  threefold.  Brunton  and  Tunnicliffe. 

extent  by  skilful  massage.  Massage  is  one  of  the  most  power- 
ful agents  in  the  treatment  of  such  cases.  It  is  a  therapeutic 
agent  of  very  great  power  and  value;  but,  like  opium,  which 


FIG.  164.  To  show  the  relief  from  fatigue  produced  by  massage.  After  Maggiora 
and  Vinaj.  Bldt.  f.  Klin.:  Hydrotherapie,  1892,  p.  6.  i.  The  fatigue  curve  of  the 
left  hand  raising  a  weight  of  3  kilogrammes  every  two  seconds.  2.  The  fatigue  curve 
of  the  left  hand.  3.  The  fatigue  curve  of  the  left  hand  after  five  minutes'  massage. 
4.  That  of  the  right  hand  without  massage.  This  tracing  is  taken  by  Mosso's 
sphygmomanometer.  (Fig.  93,  p.  72.) 

from  its  utility  has  been  termed  God's  greatest  gift  to  man, 
it  is  liable  to  abuse,  and  on  account  of  its  abuse  it  is  often 
looked  upon  askance.  But  just  as  we  cannot  afford  to  throw 

1  Vide  p.  6. 


136 


THERAPEUTICS    OF    THE    CIRCULATION 


USE    OF    REST    AND    MASSAGE 


137 


opium  aside  as  a  medicine  because  it  is  liable  to  abuse,  so  we 
must  employ  massage  if  we  are  to  do  the  best  for  our  patients, 
and  at  the  same  time  we  must  guard,  as  far  as  possible,  against 
any  chance  of  abuse.  By  slow,  firm,  upward  strokes  along 


FIG.  1 66.  Mosso's  ergograph.  It  consists  of  a  clamping  apparatus  in  which  the 
arm  is  firmly  held;  a  weight  suspended  by  a  string  which  runs  over  a  pulley,  and  ends 
in  a  loop,  into  which  one  finger  is  put.  In  the  middle  of  the  string  a  small  point 
is  fixed  which  works  upon  a  revolving  cylinder  covered  with  soot,  so  that  each  mark 
of  the  tracer  can  be  distinctly  seen.  The  finger  is  then  contracted  so  as  to  raise  the 
weight  at  intervals  of  two  seconds.  The  amount  of  contraction  is  shown  by  the 
height  of  the  up  stroke,  and  as  the  exercise  goes  on  the  contraction  becomes  shorter 
and  shorter  till  at  last  exhaustion  becomes  complete. 

the  legs  and  arms  the  venous  blood  is  forced  onwards  towards 
the  heart,  and  the  fluid  which  has  accumulated  in  the  inter- 
cellular tissue  is  driven  on  into  the  lymphatics.  Thus  the 
resistance  which  the  flow  of  blood  through  the  arterioles 
and  capillaries  has  to  overcome  is  lessened,  and  the  work  of 
the  heart  lightened.  The  weariness,  the  weight,  and  the  dis- 
comfort of  the  limbs  are  removed,  and  the  restlessness  and 
irritability  of  the  patient  lessened.  (Figs.  163-164.) 

The  combined  effect  of  rest  and  massage  is  that  the  heart 
beats  more  slowly,  beats  more  easily,  has  a  longer  period  of 
repose  between  each  beat,  and  less  work  to  do  at  each  systole, 
and  thus  the  process  .of  repair  is  allowed  to  begin. 

The  lessened  resistance  allows  each  cavity  to  contract  more 
perfectly,  the  longer  pause  allows  each  cavity  to  become  more 
full  of  blood,  the  larger  pulse-wave  sent  into  the  vessels  at 


138  THERAPEUTICS    OF    THE    CIRCULATION 

each  ventricular  contraction  increases  the  amplitude  of  the 
pulse  in  the  arteries,  and  thus  brings  about  a  more  efficient 
self-massage  in  the  arterial  walls,  and  consequently  a  more 
efficient  return  of  blood  and  lymph  from  the  veins  and  lym- 
phatics, which  accompany  the  arteries  in  their  sheaths.1 

The  heart  itself,  by  means  of  its  more  efficient  self-massage, 
'gets  rid  of  its  waste  products,  is  better  supplied  with  blood, 
and  gradually  becomes  stronger  and  stronger,  until  finally 
many  patients  who  seemed  moribund  recover  under  the  in- 
fluence of  rest  and  massage  to  such  an  extent  that  they  may 
become  practically  well  and  remain  so  for  years. 

But  it  is  not  only  on  the  heart  and  vessels  that  the  in- 
fluence of  rest  and  massage  and  the  consequent  improvement 
of  the  circulation  is  noticed.  On  account  of  the  increased 
circulation  through  the  muscles,  waste  products  are  more 
thoroughly  oxidized,  and,  the  massage  taking  the  place  of 
exercise,  a  better  appetite  for  food  is  produced,  whilst  the 


FIG.  167.  Pulse  tracing,  showing  the  effect  of  massage  and  graduated  movements. 
Each  tracing  is  taken  partly  with  a  slow  and  partly  with  a  quick  movement  of  the 
sphygmograph.  The  upper  shows  high  tension  and  a  feeble  heart;  the  lower  shows 
less  tension  and  a  stronger  heart.  These  tracings  I  owe  to  the  kindness  of  Dr. 
Gustav  Hamel,  to  whose  treatment  I  had  recommended  the  patient. 

diminished  congestion  of  the  liver,  stomach,  and  intestines 
improves  digestion,  and  thus  lessens  flatulence.  Massage  to 
the  abdomen  aids  this  process :  it  tends  to  cause  expulsion  of 
gas  from  the  stomach  and  intestines,  and  thus  decreases  the 
mechanical  interference  which  the  abdominal  distension  exerts 
upon  the  lungs  and  heart.  The  freer  circulation  tells  upon 
1  Fide  Fig.  i,  p.  6. 


EFFECT    OF,    FLATULENCE    ON    THE    HEART 


139 


the  kidneys  also.  The  urine  becomes  more  abundant  in  quan- 
tity, albumen  disappears,  waste  is  more  freely  eliminated, 
and  absorption  goes  on  both  from  the  inter-cellular  tissue  and 
serous  cavities,  so  that  the  oedema  of  the  limbs  and  accumula- 
tion of  fluid  in  the  peritoneal  or  pleural  cavities  become  ab- 
sorbed, and  the  oedema,  ascites,  or  pleural  effusion  disappears. 
Pleural  effusion  is,  of  course,  a  very  serious  complication  in 
valvular  disease,  encroaching  as  it  does  upon  the  available 
breathing  space,  and  its  appearance  should  always  be  carefully 
watched  for,  more  especially  as  its  occurrence  is  often  in- 


-CEREBELLUM 

'MEDULLA 

OBLONCATA 


••\-AFFEHENT 
I     NERVES 

- -I- -STOMACH 
~  1  WSO-INHIBlT'.l- 
I     NERVES 

-  I  INTESTINAL 
VESSELS 


FIG.  168.  Diagram  to  show  the  nervous  mechanism  by  which  the  action  of  the 
heart  may  be  depressed  by  irritation  of  the  stomach.  The  reflex  irritation  of  the 
vagus  may  render  the  heart's  action  simply  weak,  or  slow  and  weak. 

sidious.     It  is,  however,  less  common  and  less  disturbing  than 
abdominal  distension  by  gas  or  water,  or  both. 

Effect  of  Flatulence  on  the  Heart. — Flatulent  distension 
without  ascites  is  very  common  indeed,  and  so  is  flatulent 
distension  with  ascites;  but  ascites  without  flatulence  is  rare. 
The  relief  which  patients  with  cardiac  disturbance  feel  when 
flatulence  escapes  from  the  stomach  is  very  marked,  not  only 
in  cases  of  valvular  disease,  but  in  cardiac  weakness  and  in 
angina  pectoris.  The  modus  operandi  of  gastric  distension  in 
disturbing  the  action  of  the  heart  is  probably  twofold.  It  may 
depress  it  reflexly  (Fig.  168)  or  mechanically  (Fig.  169.) 


140 


THERAPEUTICS    OF    THE    CIRCULATION 


The  heart  rests  upon  the  upper  surface  of  the  stomach,  with 
only  the  thin  diaphragm  between,  and  if  the  stomach  is  dis- 
tended it  tends  to  tilt  the  heart  up  by  altering  its  position; 
it  brings  the  apex  close  to  the  chest  wall,  and  may  thus  cause 


FIG.  169.  Diagram  to  show  the  effect  of  flatulence  on  the  heart.  The  heavy  lines 
show  the  normal  position  of  the  viscera.  The  dotted  lines  show  their  position  when 
the  stomach  is  over-distended. 

palpitation.  Not  only  so,  but  it  seems  also,  by  altering  the 
axis,  to  interfere  with  the  heart's  action,  and  may  produce  dis- 
tress or  even  death.  Several  years  ago  I  saw  a  notice  of  a 
man  who  died  suddenly,  and  on  post-mortem  examination  he 
was  found  to  be  perfectly  healthy,  but  the  stomach  was  dis- 
tended with  a  mixture  of  potatoes  and  milk.  This  had  begun 
to  ferment,  and  the  pulpy  mass  being  of  an  adhesive  character, 
the  gas  was  unable  to  escape  from  it,  and  caused  such  dis- 
tension of  the  stomach  that  death  occurred. 

The  mechanism  here  is,  of  course,  uncertain,  because  the 
acute  distension  may  have  produced  reflex  stoppage  of  the 
heart,  but  in  all  probability  the  mechanical  effect  had  a  great 
deal  to  do  with  it.  A  year  or  two  ago  I  saw  another  similar 
case  recorded,  \vhere  death  was  put  down  to  tea.  In  this 
instance  the  bread  and  tea  had  apparently  formed  a  mass  like 


USE    OF    DRUGS  HI 

the  potatoes  and  milk  in  the  former  case,  and  had  a  similar 
effect.  In  former  times  one  mode  of  punishing  by  death 
was  to  make  the  condemned  person  drink  bull's  blood  warm 
from  the  vessels  of  the  slaughtered  animal.1  Blood  in  itself  is 
not  a  poison,  but  as  the  criminal  had  to  drink  it  in  large 
quantities  it  coagulated  in  the  stomach  and  formed  a  solid  clot 
which,  either  reflexly  or  mechanically,  caused  death.2  Under 
ordinary  circumstances  distension  of  the  stomach,  unless 
extreme,  will  not  displace  the  heart  and  encroach  upon  the 
lungs,  because  the  abdominal  walls  will  yield,  and  the  intes- 
tines, partially  distended  as  they  usually  are  with  gas,  will 
become  compressed  before  any  displacement  of  the  heart  can 
occur.  But  if  the  abdomen  is  distended  by  fluid,  or  if  it  is 
constricted  by  a  belt  or  by  corsets,  flatulent  pressure,  being 
prevented  from  exerting  its  force  in  a  downward  or  outward 
direction,  will  push  the  heart  up,  and  death  may  result.  For 
this  reason,  as  was  shown  by  the  Hyderabad  Chloroform  Com- 
mission, tight-lacing  is  dangerous  during  the  administration 
of  anaesthetics.3  It  tends  to  increase  the  liability  to  palpita- 
tion, and  explains  the  efficacy  of  the  common  practice  of  at 
once  loosening  the  corsets  in  case  of  fainting. 

Massage  and  Diet — Use  of  Drugs  in  Cardiac  Diseases. 
— But  useful  and  important  as  rest  and  massage  are  in  the 
treatment  of  cardiac  disease,  they  are  not  the  only  instru- 
ments for  treatment  in  the  hands  of  the  physician.  We  pos- 
sess many  drugs  which  have  a  powerful  action  on  the  heart 
and  vessels,  and  are  of  the  utmost  service  in  cardiac  disease. 
We  may  divide  such  into  (i)  cardiac  nutrients,  (2)  cardiac 
tonics,  (3)  cardiac  stimulants,  (4)  cardiac  depressants,  (5) 
vascular  contractors,  and  (6)  vascular  dilators.  In  addition 
to  these,  we  have  a  number  of  drugs  which  have  a  less  direct 
action  upon  the  heart  and  vessels  themselves,  but  rather  affect 

1  Marx,  Gtftlehre,  vol.  i.,  p.  268.     Herodotus,  Book  III.,  Thalia,  cap.  15. 
"This  explanation  was  known  to  Pliny,  Hist.  Nat.  L.,  xi.,  c.  38,  sect.  90, 
quoted  by  Marx. 
3  Lancet,  1890,  vol.  i.,  p.  662. 


142 


THERAPEUTICS    OF   THE    CIRCULATION 


FIG.  170.  Ludwig  and  Coats'  frog-heart  apparatus.  A  is  a  reservoir  for  serum. 
B,  a  stopcock  to  regulate  the  supply  to  the  heart.  C,  a  piece  of  caoutchouc  tubing 
connecting  A  and  D.  D,  a  glass  cannula  in  the  vena  cava  inferior.  Dr,  another  in 
the  aorta.  E,  a  manometer.  F,  a  piece  of  tubing  closed  by  a  clip,  to  allow  of  the 
escape  of  serum.  G,  a  fine  pen,  floating  on  the  mercury  in  E.  H,  the  frog's  heart. 
J,  a  sealed  glass  tube,  passed  through  the  oesophagus  K,  and  firmly  held  by  a  holder 
L.  M,  a  nut  which  allows  L  to  be  moved  up  and  down.  N,  a  second  holder  to  sup- 
port A.  P,  a  stand  with  upright  rod.  S,  a  flap  of  skin  to  cover  the  heart  and  pre- 
vent drying.  V,  the  vagus. 


CARDIAC    NUTRIENTS  143 

tissue  change,  and  influence  the  heart  indirectjy  through  other 
organs.  The  best  cardiac  nutrient  is,  of  course,  well  aerated 
blood  with  a  proper  proportion  of  nutrient  matter  and  little 
waste  product.  The  nutrient  materials  have  been  investigated 
one  by  one  in  experiments  at  first  upon  the  frog's  heart  (Fig. 
170),  and  latterly  upon  the  mammalian  heart.  The  method 
of  keeping  isolated  organs  alive  by  artificial  circulation  was 
invented  by  Ludwig,  and  in  the  first  experiments  which  he 
and  his  scholars  made  upon  the  frog's  heart  they  used  a  simple 
solution  of  common  salt  of  about  .5  to  .6  per  cent.,  that  is  to 
say,  about  2^  grains  to  the  ounce.  When  this  was  circu- 
lated artificially  through  the  frog's  heart  it  continued  beating 
for  a  length  of  time,  but  gradually  the  pulsations  became 
slower  and  feebler,  and  at  length  ceased  altogether.  The  ad- 
dition of  diluted  blood  usually  made  the  heart  beat  more 
strongly  for  a  longer  period,  and  when  it  stopped  the  stoppage 
was  not  due  to  exhaustion  of  the  nutrient  material,  but  the 
accumulation  of  waste.  This  was  shown  by  the  fact  that  a 
frog's  heart  when  apparently  dead  may  be  revived,  and  again 
commence  to  beat  when  the  waste  products  are  washed  out 
by  perfusion  with  normal  saline  solution  containing  a  minute 
quantity  of  sodium  hydrate.1 

Cardiac  Nutrients. — An  interesting  and  important  dis- 
covery was  made  by  Ringer,  who  found  that  when  the  saline 
solution  was  made  with  tap-water  it  maintained  the  action  of 
the  heart  for  a  very  much  longer  time  than  when  made  with 
distilled  water.  On  investigating  the  cause  of  this,  he  found 
it  was  the  lime  in  the  tap-water  which  had  a  stimulating  effect 
upon  the  heart,  and  he  was  able  to  produce  the  same  effect  by 
adding  lime  in  small  quantities  to  saline  solution  made  with 
distilled  water.2 

We  know  that  a  fire  when  allowed  to  burn  without  attention 
will  often  go  out  before  the  whole  of  the  coal  is  consumed, 
because  it  is  smothered  in  its  own  ash,  and  that  if  we  heap 

1  Gaule,  Arch.  f.  Anat.  u.  Physiol.,  physiol.  Abt.,  1878,  s.  294. 
'Ringer,  Jour,  of  Physiol.,  iv.,  p.  29. 


144  THERAPEUTICS    OF    THE    CIRCULATION 


a  be 

FIG.  171.  After  Ringer.  Tracings  showing  the  effect  of  simple  NaCl  solution 
in  weakening  the  pulsations  of  the  apex  of  the  frog's  heart.  The  tracing  a  was  taken 
soon  after  the  blood  was  replaced  by  NaCl  solution;  b,  after  a  longer  period;  and 
c  after  a  still  longer  time. 


FIG.  172.  After  Ringer.  Shows  the  effect  produced  upon  the  beat  of  the  frog's 
heart  fed  with  NaCl  solution  by  the  addition  of  a  trace  of  calcium  chloride.  The 
beats  in  this  case  are  induced  by  an  induction  shock. 


FIG.    173.       Tracing  showing  enormous  contraction   of  the   gastrocnemius   of  the  frog 
by  a  solution  of  caffeine. 


DIGITALIS    AND    ITS    CONGENERS  145 

ashes  on  the  fire  we  tend  to  put  it  out.  But  the  result  is 
different  if  we  use  cinders  instead  of  ash;  and  although  cin- 
ders represent  half-burned  coal,  they  are  sometimes  very 
useful  in  keeping  up  a  fire  or  in  helping  it  to  burn  when  it 
is  low.  In  the  same  way  the  ashes,  as  we  may  term  them, 
of  the  tissues  tend  to  smother  the  vital  fires,  and  to  prevent 
the  tissues  from  performing  their  proper  functions;  but  the 
vital  cinders,  that  is,  substances  which  are  derived  from  albu- 
mens and  are  on  the  way  to  urea  or  uric  acid,  may  be  very 
useful.  Amongst  these  we  have  a  series  of  bodies  to  which 
the  term  of  purin  bodies  has  been  applied — xanthine,  hypo- 
xanthine,  methylxanthine,  dimethylxanthine  or  theobromine, 
and  trimethylxanthine  or  caffeine.  All  these  bodies  are  prob- 
ably injurious  in  large  quantities,  but  just  as  a  few  cinders 
may  help  a  fire,  so  when  used  in  small  quantities  they  are 
often  very  useful.  Beef-tea  and  extracts  of  meat  have  little 
or  no  nutritive  action,  and  life  cannot  be  sustained  upon  them, 
but  they  are  useful  stimulants,  as  was  shown  by  Parkes  in  the 
Ashanti  campaign;1  and  in  disease  they  act  as  cardiac  stimu- 
lants, although  hardly  as  cardiac  nutrients.  Amongst  the 
most  powerful  cardiac  nutrients  appears  to  be  glucose;  for 
Locke  found  in  his  experiments  that  the  addition  of  glucose, 
even  in  very  small  quantity,  to  a  saline  fluid  greatly  increased 
its  nutritive  effect  upon  the  isolated  mammalian  heart.  Other 
sugars  have  less  action.  Their  nutritive  effect  apparently  runs 
parallel  with  their  susceptibility  to  fermentation,  glucose  stand- 
ing far  ahead  of  the  others.  Caffeine  in  large  doses  acts  as 
a  muscular  poison,  and  tends  to  cause  strong  contraction,  end- 
ing in  rigor  of  the  muscle.  Its  effect  in  small  doses  upon  the 
heart  appears  to  be  that  it  increases  the  muscular  contraction, 
and  strengthens  the  ventricular  beats. 

Digitalis  and  its  Congeners. — The  most  important  drug 
of  all,  however,  in  the  treatment  of  heart  disease  is  digitalis. 
Although  this  drug  has  been  used  for  a  long  time,  yet  it  is 
only  within  the  last  forty  years  or  so  that  its  action  has  really 

1  Parkes. 
1 1 


146  THERAPEUTICS    OF    THE    CIRCULATION 

become  generally  understood.  Even  when  I  was  a  student, 
digitalis  was  looked  upon  as  a  cardiac  depressant  to  be  used 
with  great  care  in  enfeebled  hearts,  whereas  now  it  is  uni- 
versally regarded  as  a  cardiac  tonic.  Although  Blake  in  1839 
showed  that  digitalis  injected  into  the  arterial  system  greatly 
raised  the  blood  pressure,  yet  the  physiological  action  of  the 
drug  was  not  further  investigated  until  Traube  made  his  ex- 
periments in  1862  on  the  mammalian  circulation,  and  Fagge 
and  Stevenson  on  the  frog's  heart.  In  1865  I  wrote  my 
Thesis  on  Digitalis,  and,  I  think,  for  the  first  time,  brought 
into  relation  the  double  action  of  digitalis  both  on  the  heart 
and  the  vessels,  as  well  as  giving  the  first  definite  proof  that 
the  cardiac  action  in  mammals  was  actually  strengthened  and 
not  weakened  by  this  drug.1 

Digitalis  is  an  example  of  a  very  widely  distributed  group 
of  poisons,  many  of  which  are  used  in  various  parts  of  the 
world  for  poisoning  arrows,  either  for  use  in  the  chase  or  in 
war.  Those  which  are  most  commonly  used  in  medicine  are 
the  strophanthus  hispidus  and  squill  (Scilla  maritima). 
Amongst  those  occasionally  but  less  frequently  employed  are, 
casca  or  sassy  bark  (Erythrophlosum  gmnenense} ,  lily  of  the 
valley  (Convallaria  majalis},  Canadian  hemp  (Apocynum 
cannabinum},  pheasant's  eye  (Adonis  vernalis},  and  Christ- 
mas rose  (Helleborus  niger}.  Other  plants  having  a  similar 
action,  but  not  used,  are  Antiaris  toxicaria  (upas),  Nerium 
oleander,  Acocanthera  (oubain),  Thevetia  grandiflora,  and 
Coronilla.  A  poison  having  a  similar  action  is  obtained  from 
the  skin  of  toads.  It  is  called  phrynin,  and  though  not  em- 
ployed much  in  medicine,  it  has  proved  useful.  The  story 
is  told  that  the  husband  of  an  Italian  woman  was  dying  of 
heart  disease,  with  dropsical  limbs  and  all  the  usual  accompani- 
ments. As  his  death  was  so  slow,  his  good  wife  thought  she 

'Brunton,  "On  Digitalis,"  pp.  28,  31.  Churchill,  London,  1868.  Re- 
printed in  Collected  Papers  on  Circulation  and  Respiration,  pp.  52,  55. 
Macmillan,  London,  1906.  This  paper  was  presented  as  a  graduation 
thesis  to  the  University  of  Edinburgh  in  1866,  but  was  not  published  until 
1868.  This  paper  also  gives  the  early  literature  of  the  subject. 


ACTION    OF   DIGITALIS    ON    THE    FROG  S    HEART 


147 


would  quicken  his  journey  into  the  other  world,  and  accord- 
ingly she  went  into  the  garden,  where  she  found  several  toads. 
These  she  dropped  into  the  wine  her  husband  was  to  drink; 
but  instead  of  his  dying  forthwith,  as  she  expected,  he  began 
immediately  to  get  well,  the  phrynin  from  the  toad's  skin 
having  had  upon  him  the  same  beneficial  effect  that  a  course 
of  digitalis  would  have  had. 

Resume  of  the  Action  of  Digitalis. — Digitalis  acts  on  the 
cardiac  muscle,  the  intrinsic  cardiac  nerves,  and  the  vagus 
center  in  the  medulla.  It  also  affects  the  arterioles,  causing 
them  to  contract,  and  probably  it  has  upon  them  also  a  two- 
fold action,  as  on  the  heart,  and  stimulates  both  the  contractile 
muscular  walls  and  the  nerves  which  go  to  them.  The  action 


OU.  0  C. 

FIG.  174.  Diagram  to  show  the  action  of  digitalis  in  the  frog's  heart;  a  is  the 
normal  heart  in  which  both  auricle  and  ventricle  are  filled  with  blood  during  the 
diastole;  b  is  the  heart  with  the  ventricle  becoming  contracted  and  showing  the  yielding 
pouches;  c  is  the  heart  fully  under  the  influence  of  digitalis  with  the  ventricle  firmly 
contracted  so  that  it  will  not  admit  any  of  the  blood  which  distends  the  auricle. 

upon  the  heart  of  the  frog  is  very  marked  and  characteristic, 
and  the  action  here  is  less  complicated  than  in  mammals, 
inasmuch  as  the  heart  itself  is  less  under  the  control  of  the 
central  nervous  system,  and  is  less  readily  affected  by  altera- 
tions which  may  occur  in  the  vessels.  When  the  excised  heart 
of  a  frog  is  either  laid  in  a  solution  containing  the  active 
principles  of  digitalis  or  is  connected  with  an  apparatus  by 
which  serum  containing  these  principles  may  be  circulated 
through  it,  changes  are  observed,  which  may  be  divided  into 
changes  in  rate  of  pulsation  and  changes  in  character  of  pulsa- 
tion. The  heart  first  of  all  begins  to  pulsate  more  slowly, 


148  THERAPEUTICS    OF    THE    CIRCULATION 

and  at  the  same  time  more  powerfully;  the  contractions 
become  gradually  stronger,  and  the  relaxation  or  diastole 
becomes  less  perfect,  so  that  finally  the  heart  stands  still 
altogether  in  a  state  of  complete  contraction.  If  the  heart 
which  is  thus  standing  still  be  forcibly  dilated,  by  passing 
fluid  into  its  interior  under  pressure,  pulsation  will  recom- 
mence. Occasionally  during  the  process  of  contraction  small 
points  on  the  surface  of  the  heart  may  be  observed,  which  re- 
main dilated,  and  look  like  small  purple  pulsatile  pouches  on 
the  surface  of  the  organ.1  The  nature  of  these  pouches  has 
not  been  definitely  ascertained,  but  it  is  not  improbable  that 
they  are  due  to  slight  injury  of  the  muscular  fiber  in  the  proc- 
ess of  removing  the  heart  from  the  body  of  the  frog.  When 
the  heart  of  a  frog  is  lift  in  situ,  and  is  merely  exposed  to 
view  by  opening  the  thorax  of  the  animal,  and  dropping  a 
solution  of  digitalis  upon  it,  the  same  phenomena  are  observed. 
They  are  unaltered  by  the  use  of  atropine,  and  are  supposed 
to  be  due  to  the  action  of  the  drug  upon  the  muscular  fibers 
of  the  heart  itself. 

1  Fagge  and  Stevenson,  Roy.  Soc.  Proc.,  xiv.,  p.  270. 


LECTURE  VI 

Action  of  Digitalis  in  Mammals — Uses  of  Digitalis — Action  of  Digitalis 
on  (Edema — Toxic  Action  of  Digitalis — Action  of  Digitalis  on  Arterioles 
— Stages  in  the  Action  of  Digitalis — Difference  between  Digitalis  and  other 
Cardiac  Tonics — Action  of  Strychnine  on  the  Heart — Action  of  Caffeine 
and  other  Purin  Bodies — Drawbacks  to  the  Action  of  Digitalis  and  other 
Cardiac  Tonics — Removal  of  these  Drawbacks  by  Combination — Vaso- 
dilators :  amyl  nitrite,  isobutyl  nitrite,  hydroxylamine,  nitroglycerine,  nitro- 
erythrite,  nitromannite,  sodium,  and  other  nitrites. 

Action  of  Digitalis  in  Mammals. — In  mammals,  digitalis 
causes  increased  contraction  of  the  muscular  fibers,  both  (i) 
in  the  heart  and  (2)  the  arteries.  This  increased  contraction 
appears  to  be  partly  due  to  the  action  of  digitalis  on  the  mus- 
cular fibers  themselves,  but  its  effect  upon  the  muscle  is  greatly 
modified  by  its  action  upon  the  nervous  system.  Its  action 
is  exerted  especially  upon  the  medulla  oblongata,  and  it  appears 
to  affect  first  the  inhibitory  center  of  the  vagus  and  the  vaso- 
motor  center  for  the  vessels.  When  small  doses  are  given, 
the  effect  appears  to  be  limited  to  these  centers,  but  when  the 
administration  is  carried  to  the  extent  of  poisoning,  the  ad- 
jacent respiratory  and  vomiting  centers  are  also  affected. 
From  stimulation  of  the  vagus  center,  the  pulse  becomes  slow, 
and  the  diastole  more  complete,  while  at  the  same  time  the 
stimulation  of  the  muscular  fibers  of  the  heart  makes  its  con- 
tractions more  powerful.  Its  beats  thus  become  much  more 
efficient;  the  longer  intervals  between  them  afford  the  heart 
time  for  recuperation;  the  more  complete  diastole  allows  a 
larger  quantity  of  blood  to  accumulate  in  its  cavities,  the  more 
powerful  systole  drives  this  onward,  the  self-massage  of  the 
heart  becomes  more  complete,  and  all  the  good  effects  which  I 
have  mentioned  as  occurring  from  this  are  noticed  after  the 
action  of  digitalis.  One  consequence  which  is  of  special  in- 
terest is  its  diuretic  action.  This  is  partly  due  to  the  rise  in 
blood  pressure  which  it  produces,  and  which  raises  the  pres- 

149 


ISO  THERAPEUTICS    OF    THE    CIRCULATION 

sure  in  the  glomeruli,  drives  the  blood  more  quickly  through 
the  kidneys,  and  causes  a  more  rapid  secretion  of  urine.  At 
the  same  time  it  is  probable  that  digitalis  has  a  certain  stimu- 
lating effect  on  the  secreting  structures  in  the  kidneys  them- 
selves, a  stimulation  which  may  extend  also  to  other  parts  of 
the  genito-urinary  tract.  This  effect,  however,  is  not  so 
great  as  that  produced  by  caffeine,  and  the  diuretic  action  of 
digitalis  is  probably  exerted  chiefly  through  the  circulation. 
When  digitalis  acts  upon  a  healthy  man  so  as  to  produce 
diuresis,  the  drain  of  fluid  becomes  so  great  that,  as  I  have 
found  in  my  own  experiments,  the  thirst  it  induces  becomes 
intolerable,  and  water  must  be  taken  in  order  to  allay  it.1 

In  cardiac  diseases  with  oedema,  or  accumulation  of  fluid  in 
the  serous  cavities,  such  drinking  is  unnecessary,  as  the  fluid 
drained  away  from  the  blood  by  the  kidneys  is  supplied  by 
absorption  from  the  subcutaneous  tissue  or  from  the  serous 
cavities. 

Uses  of  Digitalis. — Not  only  does  the  circulation  in  the 
tissues  generally  improve  under  digitalis,  but  the  nutrition  of 
the  heart  is  increased  by  more  efficient  circulation  through  the 
coronary  vessels;  dilatation  is  lessened;  the  muscular  rings 
around  the  auriculo-ventricular  orifices  contract  more  strongly, 
the  mitral  and  tricuspid  valves  close  them  more  efficiently,  and 
regurgitation  is  lessened.  In  cases  where  the  valvular  incom- 
petency  is  solely  due  to  dilatation  and  not  to  changes  in  the 
valves  themselves,  the  incompetency  may  be  completely  cured. 

The  arteries  likewise  benefit,  as  the  slower  and  stronger 
beats  of  the  heart  increase  the  self-massage  of  the  artery  in  its 
sheath,  and  the  same  increased  pulsation  aids  the  circulation  in 
the  veins,  as  already  described.  The  venous  circulation  is 
farther  aided  by  increased  suction-power  of  the  heart  (Fig. 
125,  p.  96),  which  contracts  more  rapidly  and  completely. 
Diminished  regurgitation  combines  with  increased  circulation 
in  the  veins  to  lessen  venous  congestion,  and  thus  tends  to 

1Lauder  Brunton  on  "Digitalis,"  Collected  Papers,  p.  83.  Macmillan  & 
Co.,  London,  1906. 


DIURESIS USES    OF    DIGITALIS 


increase  the  secretion  of  urine.     For  venous  congestion  in  the 
kidneys  tends  to  compress  the  arterioles  and  tubules  in  the 


FIG.  175.      Heart  fully  distended,  showing  insufficiency  of  the  valves  to  close  the  mitral 
and  tricuspid   orifices. 

organ,  and  thus  lessen  secretion;  and  digitalis,  therefore,  in 
cases  of  venous  congestion  probably  acts  as  a  diuretic  in  four 


FIG.  176.  Heart  in  full 
systole,  showing  the  mitral 
and  tricuspid  orifices  so  di- 
minished by  the  muscular  con- 
traction that  the  valves  close 
them  easily. 


FIG.  177.  The  same  heart 
as  in  Fig.  176,  from  another 
point  of  view. 


ways — (i)  it  increases  the  blood  pressure  in  the  glomeruli; 
(2)   it  lessens  the  resistance  which  the  pressure  of  the  dis- 


152 


THERAPEUTICS    OF   THE    CIRCULATION 


tended  venous  radicles  in  the  kidney  opposes  to  secretion;  (3) 
it  probably  acts  as  a  stimulant  to  the  secreting  cells  of  the 
kidney;  and  (4)  it  increases  the  volume  of  blood,  and  some- 
what alters  its  composition  by  causing  absorption  from  cedem- 
atous  tissues  and  serous  cavities.  When  it  causes  absorp- 
tion of  ascitic  fluid  from  the  abdominal  cavity  it  may  act  as 
a  diuretic  in  a  fifth  way,  viz.,  by  lessening  the  resistance  op- 
posed to  the  secretion  of  urine  by  the  pressure  of  the  ascitic 
fluid  on  (a)  the  kidney  itself,  and  (b)  on  the  ureters.  From 
this  manifold  action  of  digitalis  as  a  diuretic  it  is  evident  that 
when  its  action  is  once  fairly  established  in  a  water-logged 


FIG.  178.  Diagram  to  show  the  effect 
of  venous  congestion  and  of  obstruction  of 
the  ureter  or  tubules  on  the  kidney.  A, 
normal  kidney,  with  artery  in  the  center 
of  the  hilus.  The  artery  ends  in  a. 
glomerulus  from  which  a  urinary  tubule 
passes  into  the  ureter,  which  is  shown 
passing  out  of  the  hilus  below  the  artery. 
The  renal  vein  is  shown  above  the  artery 
in  the  hilus.  B  shows  congestion  of  the 
vein,  with  consequent  compression  of  the 
artery  and  tubule.  C  shows  obstruction  of 
the  ureter  and  tubules. 


FIG.  179.  Diagrammatic  section 
of  the  abdomen:  A,  in  the  normal 
state;  B,  in  advanced  dropsy,  where 
the  ascitic  fluid  compresses  the  kid- 
ney itself  and  also  the  ureter,  so 
that  the  secretion  of  urine  is  hind- 
ered in  two  ways:  (i)  by  pressure 
on  the  outside  of  the  kidney,  and 
(2)  by  pressure  on  the  inside  of  the 
kidney  from  the  tension  in  the 
urinary  tubules. 


patient,  the  amount  of  urine  secreted  for  some  days  may  be 
enormous. 

Action  of  Digitalis  on  CEdema. — As  I  have  already  men- 
tioned, the  diuretic  action  of  digitalis  may  cause  so  much  water 
to  be  withdrawn  from  the  blood  that  it  produces  a  consuming 
thirst  in  a  healthy  man.1  In  a  dropsical  one,  the  fluid  lost 
through  the  kidneys  is  made  up  by  absorption  from  the  tissues, 
and  this  is  one  way  in  which  digitalis  reduces  oedema.  But  it 

'Lauder   Brunton   on   "Digitalis,"   Notes   of   March   17   and    19,    1865. 
Collected  Papers  on  Circulation  and  Respiration,  p.  83. 


ACTION    OF    DIGITALIS    ON    (EDEMA 


153 


is  probably  not  the  only  one.  For  digitalis  stimulates  the  vaso- 
motor  nerves,  and  in  this  way  tends  to  prevent  the  exudation 
of  fluid  from  the  blood-vessels,  which  produces  oedema.  It  is 


ARTER/ES 


FIG.  1 80.  Diagram  of  Ranvier's  experiment  on  dropsy.  The  vena  cava  is 
ligatured,  and  in  the  left  leg  the  trunk  of  the  sciatic  has  been  divided  so  that  both 
the  motor  and  vaso-motor  nerves  contained  in  it  are  paralyzed.  On  the  right  side  the 
motor  roots  of  the  sciatic  alone  are  divided  and  the  vaso-motor  left  uninjured. 
There  is  thus  motor  paralysis  on  both  sides,  but  vaso-motor  paralysis  and  dropsy  only 
on  the  left  side. 

universally  acknowledged  that  venous  obstruction  tends  to 
produce  oedema,  but  at  the  same  time  oedema  may  occur  with- 
out any  obvious  venous  obstruction,  as  in  angio-neurotic 
cedema.  Moreover,  venous  obstruction  may  exist  without 
oedema,  as  was  shown  by  Ranvier,  who  tied  the  vena  cava  in 
a  dog,  and  found  that  although  venous  congestion  was  thus 
produced  in  both  legs,  no  oedema  occurred  in  the  leg  where 
the  vaso-motor  nerves  were  left  intact,  but  occurred  in  the 
other  where  the  vaso-motor  nerves  were  divided. 

Another  benefit  resulting  from  diminished  venous  conges- 


154  THERAPEUTICS    OF   THE    CIRCULATION 

tion  is  improved  digestion  and  assimilation.  The  liver,  which 
under  increased  venous  pressure  may  have  become  so  swollen 
as  to  reach  even  below  the  umbilicus,  returns  more  or  less  to 
its  normal  size,  and  the  obstacle  which  had  existed  to  the  re- 
turn of  venous  blood  from  the  stomach  and  intestines,  nearly 


FIG.    181.       Diagram  to   show   the  return   of  venous  blood   from   the  stomach   and  in- 
testines  through    the    liver. 

all  of  which  has  to  pass  through  the  liver,  is  removed  (Fig. 
181).  The  circulation  through  these  organs  becomes  better, 
digestion  and  absorption  improve,  flatulence  is  lessened,  and 
the  patient's  nutrition  improves. 

Toxic  Action  of  Digitalis. — All  these  are  the  advantages 
which  we  gain  from  the  proper  administration  of  digitalis; 


TOXIC  ACTION  OF  DIGITALIS 


155 


but  when  carried  too  far,  a  toxic  action  occurs,  and  one  of  the 
first  symptoms  is  nausea  and  vomiting.  This  may  be  due 
simply  to  extension  of  the  irritation  in  the  medulla  from  the 
vagus  and  vaso-motor  centers  to  the  vomiting  center,  but  it 
.may  be  due  also,  to  some  extent,  to  a  local  irritation  of  the 
stomach  by  the  digitalis  being  secreted  into  it  in  the  same  way 
as  tartar  emetic,  or  the  toxins  of  cholera.  In  medical  practice, 
gastric  irritation  is  usually  one  of  the  first  indications  that 
the  physiological  effect  of  digitalis  is  passing  into  its  toxic 
action.  Sometimes,  however,  the  pulse  becomes  abnormally 
slow,  even  before  sickness  occurs.  If  the  warning  given 
either  by  sickness  or  by  the  pulse  is  attended  to,  and  the  ad- 
ministration of  the  drug  is  stopped,  usually  no  further  dis- 
advantage occurs :  but  if  these  warnings  be  unheeded,  exces- 


FIG.  182.  Diagram  to  show  the  relation  between  blood  pressure  and  the  secretion 
of  urine  after  the  administration  of  erythrophlceum.  The  lower  tracing  shows  the 
blood  pressure  in  millimeters  of  mercury.  The  upper  shows  the  secretion  of  urine 
in  minims  per  ten  minutes.  It  may  be  noted  that  when  the  blood  pressure  rises  to 
its  maximum  of  200,  the  secretion  of  urine  falls  to  zero. 

sive  vomiting  may  set  in,  collapse  may  occur,  and  the  secre- 
tion of  urine  may  be  entirely  arrested.  The  secretion  of  urine 
may  cease  at  the  time  when  the  blood  pressure  is  at  its  maxi- 
mum, as  I  found  along  with  Mr.  Power  in  the  case  of  digi- 


156 


THERAPEUTICS    OF    THE    CIRCULATION 


talis,  and  along  with  Mr.  Pye  in  the  case  of  strophanthus. 
The  stoppage  of  secretion  is  exactly  like  that  which  occurs 
from  ligature  of  the  renal  artery,  and  in  all  probability  it  is 


100 


90 


80 


70 


60 


FIG.  183.  Tracings  to  show  the  first  stages  of  the  action  of  digitalis.  Brunton 
and  Meyer — Tracing  of  the  oscillations  of  blood  pressure  in  a  dog.  There  are  nearly 
5  beats  of  the  heart  in  the  tracing  and  the  pressure  falls  to  55  mm.  of  mercury  and 
rises  to  94. 

due  to  spasm  of  these  arteries  stopping  the  circulation  through 
the  kidney.  As  the  pressure  begins  to  fall  and  the  arteries 
relax,  urine  is  again  secreted,  but  it  is  often  albuminous, 


FIG.  184.      Tracing  from  same  animal  after  the  administration  of  digitalis.      The  slow- 
ing of  the  heart  is  very  marked,  the  pressure  is  somewhat  raised. 

exactly  like  the  urine  secreted  after  the  arteries  have  been 
ligatured  and  then  released. 


ACTION    OF   DIGITALIS    ON    ARTERIOLES 


157 


Action  of  Digitalis  on  Arterioles. — The  rise  of  blood  pres- 
sure which  digitalis  produces  was  attributed  by  Traube  and 


no 


FIG.  185.  Tracing  from  the  same  animal  when  the  action  of  digitalis  is  more  pro- 
nounced. The  difference  between  this  and  the  previous  tracing  does  not  consist  so 
much  in  any  further  slowing  of  the  pulse  but  in  the  smaller  oscillation  and  the  rise 
in  tension. 

von  Bezold  to  increased  action  of  the  heart,  and  they  left  the 
arterioles  altogether  out  of  account  as  a  factor  in  its  produc- 


tic.  1 86.  Tracing  of  the  blood  pressure  of  a  dog  during  arrest  of  the  heart  by 
electrical  stimulation  of  the  vagus  before  injection  of  digitalis.  It  will  be  noticed 
that  during  the  stoppage  the  blood  pressure  falls  to  within  1.5  cm.  of  the  abscissa. 

tion.  In  my  thesis,  presented  to  the  Edinburgh  University 
in  1866,  I  pointed  out  the  importance  of  the  arterioles,  and 
in  the  winter  of  1867-68  I  obtained,  in  conjunction  with  A. 


I$8  THERAPEUTICS    OF   THE    CIRCULATION 

B.  Meyer,  experimental  evidence  of  this  action.1  We  noticed 
that  after  the  injection  of  digitalis  into  the  veins  of  a  dog, 
the  pressure  in  the  arteries  not  only  rose  higher  than  before, 
but  it  fell  more  slowly  during  diastole.  Had  the  arterioles  not 
been  contracted,  the  higher  pressure  would  have  driven  the 
blood  more  quickly  through  them  in  diastole,  and  so  the  fall 
would  have  been  quicker  than  before,  instead  of  being  slower, 
as  we  found  it  to  be.  In  order  to  obtain  more  certain  proof 
of  this,  however,  I  then  took  up  the  question  along  with  Dr. 
Tunnicliffe,  and  instead  of  using  the  normal  systole  of  the 
heart  we  prolonged  it  greatly  by  irritation  of  the  vagus.  The 


FIG.  187.  The  same  experiment  as  in  Fig.  186,  but  after  the  injection  of  digitalis. 
Although  the  arrest  of  the  heart  is  longer  than  in  the  previous  experiment,  the  blood 
pressure  only  falls  to  within  3  cm.  of  the  abscissa  instead  of  to  1.5  cm. 

results  we  arrived  at  entirely  confirmed  my  previous  observa- 
tions ;  for,  although  the  pressure  was  considerably  raised  in 
the  arteries  by  the  administration  of  digitalis,  it  fell  very  much 
more  slowly  than  in  the  normal  animal,  while  the  heart  was 
standing  still  from  irritation  of  the  vagus.  I  need  not  enter 
further  into  the  discussion  of  this  point,  as  Tunnicliffe  and  I 
have  gone  fully  into  it  in  our  paper.2 

Stages  in  the  Action  of  Digitalis. — The  action  of  the  drug 

1  Brunton  and  Meyer,  Jour,  of  Anat.  and  Physiol.,  vol.  vii.,  1873,  and 
reprinted  in  Collected  Papers,  p.  141. 

2  Lander  Brunton  and  Tunnicliffe,  Journ.  of  Physiol,  1896,  vol.  xx.,  p.  354. 


STAGES    IN    THE    ACTION    OF    DIGITALIS 


159 


may  be  divided  into  several  stages.  These  stages  have  been 
variously  described,  so  that  the  stages  of  different  authors  do 
not  correspond.  The  essential  part  of  the  division  is  that  in 
the  first  stage  there  is  increased  power,  both  of  those  parts 
of  the  nervous  system  connected  with  the  heart  and  vessels 
and  of  the  muscular  fibers  in  them,  while  in  the  later  stages 


FIG.  188.  Tracings  of  blood  pressure  showing  the  action  of  digitalis.  The  first  is 
normal;  the  second,  slow  pulse  with  rise  of  pressure;  third,  paralyzed  vagus  with  con- 
tracted arterioles;  fourth,  vessels  relax. 

more  or  less  complete  paralysis  of  these  structures  occurs. 

We  might,  then,  take  as  the — 

1st  stage,  that  in  which  there  is  increased  action  in  all  the 
nerves  and  muscles  of  the  circulation ;  as  the 

2d,  that  in  which  the  nervous  system  of  the  heart  begins 
to  fail,  while  muscular  power  and  the  whole  vascular  apparatus 
are  still  intact;  as  the 


I6O  THERAPEUTICS    OF    THE    CIRCULATION 

3d,  that  in  which  the  muscular  fiber  of  the  heart  begins  to 
fail;  and  as  the 

4th,  that  in  which  the  vessels  become  enfeebled. 

In  the  first  stage  we  have  a  rise  of  blood  pressure  and 
usually  a  slowing  of  the  pulse,  this  slowing  being  due  to  the 
action  of  the  drug  both  on  the  vagus  roots  and  ends  in  the 
heart.  Although  the  pulse  is  slow,  the  systole  of  the  heart  is 
not  prolonged,  and  there  is,  therefore,  a  much  longer  diastole 
during  which  the  heart  is  able  to  rest.  The  blood  pressure  in 
the  kidneys  is  increased  as  well  as  in  the  other  organs,  and  the 
urinary  secretion  is  therefore  augmented.  In  the  second  stage, 
while  the  blood  pressure  continues  high,  the  vagus  becomes 
partially  paralyzed,  and  therefore  the  pulsations  become  at  first 
irregular  and  afterwards  very  rapid.  In  this  condition  spasm 
of  the  renal  vessels  may  occur,  and  the  urinary  secretions  may 
entirely  cease.  When  this  occurs  in  man,  the  condition  of  the 
patient  is  dangerous.  In  the  third  stage  the  heart  becomes 
feebler,  and  may  again  become  regular,  from  failure  either  of 
the  muscular  fiber  itself  or  the  intrinsic  ganglia.  The  arterioles 
now  relax,  the  blood  pressure  begins  to  fall,  and  the  urine  may 
again  become  copious.  In  the  fourth  stage,  the  vessels  dilate 
generally,  blood  pressure  falls  very  greatly,  and  the  heart  stops 
sometimes  in  systole,  as  in  the  frog,  but  very  frequently  in 
diastole. 

Difference  between  Digitalis  and  other  Cardiac  Tonics. 
— The  differences  which  have  been  observed  between  the  ac- 
tion of  digitalis  and  its  congeners  are  that,  while  digitalis 
affects  both  heart  and  vessels,  the  action  of  strophanthus 
appears  to  be  exerted  more  especially  upon  the  heart,  increas- 
ing its  power;  while  that  of  erythrophlceum  appears  to  be  ex- 
erted more  upon  the  vessels. 

Action  of  Adrenaline  on  the  Heart  and  Vessels. — This 
substance  when  injected  into  the  circulation  causes  a  contrac- 
tion of  the  vessels  and  rise  of  blood  pressure,  such  as  almost 
no  other  substance,  except  nicotine,  p.  167,  will  produce.  It 
is  also  a  powerful  stimulant  of  the  heart.  Unfortunately,  its 


STRYCHNINE CAFFEINE OTHER    PURIN    BODIES          l6l 

action  is  transient,  and  when  given  by  the  mouth,  its  action 
is  much  less  than  when  given  hypodermically, 

Action  of  Strychnine  on  the  Heart. — Another  drug  be- 
longing to  quite  a  different  class,  and  yet  most  useful  in  cardiac 
disease,  is  strychnine.  Its  action  is  exerted  slightly,  if  at  all, 
upon  the  muscular  fiber,  but  it  greatly  increases  the  reflex 
excitability  of  nerve  centers.  This  is  more  especially  marked 
in  those  of  the  cord  and  medulla,  but  it  also  stimulates  peri- 
pheral ganglia,  and  Cash  and  I  found  that  when  applied  to  the 
heart  it  prevented  the  slowing  or  stoppage  of  the  ventricle, 
which  usually  occurs  from  the  application  of  a  ligature  be- 
tween the  venous  sinus  and  the  ventricle.1  In  some  books  on 
Pharmacology  the  action  of  strychnine  as  a  cardiac  stimulant 
is  to  a  great  extent  ignored;  but  I  think  that  in  medical  prac- 
tice the  use  of  this  drug  as  a  cardiac  stimulant  has  of  late 
years  become  more  and  more  general,  and  it  is  justified  by  the 
good  effects  observed  from  it,  and  explained,  partly  at  least, 
by  the  action  on  the  heart  which  Cash  and  I  found  it  to  have. 
Under  its  use  we  frequently  notice  that  a  pulse  which  was 
previously  feeble,  irregular,  or  intermittent,  becomes  steady, 
strong,  and  regular.  No  doubt,  the  conditions  which  regu- 
late the  pulse  are  very  complicated  in  health,  and  still  more 
in  disease,  so  that  it  is  difficult  or  impossible  to  be  absolutely 
certain  of  the  exact  mode  of  action  of  strychnine;  but  at  the 
same  time  its  good  effects  are,  I  think,  undeniable,  and  the 
explanation  that  I  have  given  is  at  any  rate  feasible. 

Action  of  Caffeine  and  other  Purin  Bodies. — While 
strychnine  exerts  its  beneficial  effect  almost  entirely  through 
the  nerves,  caffeine  and  allied  bodies  probably  exert  it,  more 
especially,  through  their  action  upon  the  muscular  fiber  of  the 
heart  and  arteries  and  upon  the  secreting  cells  in  the  kidneys. 
This  is  not  entirely  the  case,  however,  for  all  the  plants  which 
contain  either  caffeine  or  theobromine  are  used  dietetically  as 

1  Brunton  and  Cash,  "  On  the  explanation  of  Stannius's  experiment,  and 
on  the  Action  of  Strychnia  on  the  Heart,"  St.  Bartholomew's  Hospital 
Reports,  vol.  xvi.,  1880,  reprinted  in  Collected  Papers,  p.  556,  cf.  p.  21. 


1 62  THERAPEUTICS    OF   THE    CIRCULATION 

nervous  stimulants;  tea,  coffee,  and  chocolate  being  the  most 
commonly  employed,  but  kola  and  guarana  being  also  largely 
used  in  Africa  and  South  America.  Like  digitalis,  caffeine 
stimulates  the  vaso-motor  center  in  the  medulla  and  raises  the 
blood-pressure  by  causing  contraction  of  the  vessels;  but  this 
rise,  instead  of  being  accompanied  by  a  slow  pulse,  as  in  the 
case  of  digitalis,  usually  goes  along  with  an  acceleration  of  the 
heart  beats.  The  reason  of  this  probably  is  that  the  cardiac 
muscle  is  rendered  by  caffeine  more  irritable,  so  that  its  rhyth- 
mical stimuli  follow  one  another  more  quickly,  while  at  the 
same  time  its  contraction  becomes  more  powerful.  The  effect 
upon  the  kidneys  is  to  produce  a  considerably  increased  flow 
of  urine,  and  the  increase  of  water  is  accompanied  also  by  an 
increase  in  the  solids,  the  total  effect  being  chiefly  due  to  stimu- 
lation of  the  secreting  cells.  Theobromine  differs  from  caf- 
feine in  having  much  less  effect  upon  the  vaso-motor  center 
and  more  effect  upon  the  kidney  itself.  It  therefore  acts  more 
powerfully  as  a  diuretic  than  caffeine.  It  is  sparingly  soluble 
in  water,  but  is  rendered  more  soluble  by  trisodium  phosphate, 
and  several  synthetic  compounds  have  been  introduced  into 
medicine.  One  is  called  diuretin,  which  is  said  to  be  a  sali- 
cylate  of  sodium  and  theobromine ;  agurin,  which  is  an  acetate 
of  sodium  and  theobromine;  an  iodide  of  sodium  and  theo- 
bromine; and  uropherin,  which  is  a  salicylate  of  lithium  and 
theobromine.  Another  substance,  also  found  in  tea  and  coffee, 
theophyllin,  has  been  made  synthetically,  and  is  sold  under 
the  name  theocine.  All  these  substances  are  useful  diuretics, 
and  may  be  given  either  alone  or  in  combination  with  digitalis, 
strophanthus,  or  other  drugs  having  a  similar  action. 

Drawbacks  to  the  Action  of  Digitalis  and  other  Cardiac 
Tonics. — All  the  drugs  of  which  we  have  hitherto  been  speak- 
ing have  a  tendency  to  cause  contraction  of  the  vessels.  This 
tendency  may  interfere  with  their  beneficial  effects  by  caus- 
ing contraction  of  the  renal  arteries,  and  thus  checking  the 
secretion  of  urine;  but  a  greater  drawback  sometimes  is  that, 
by  contracting  the  vessels  generally,  they  raise  the  blood  pres- 


DRAWBACKS    TO    CARDIAC    TONICS  163 

sure  and  thus  increase  the  resistance  which  the  heart  has  to 
overcome,  and  consequently  the  work  it  has  to  do.  If  the 
heart  is  very  feeble  it  may  even  become  unable  to  overcome 
the  increased  tension,  and  sudden  and  fatal  syncope  may  ensue. 
Fatal  syncope  has  not  un  frequently  resulted  from  the  exces- 
sive use  of  digitalis,  and  it  appears  to  be  more  apt  to  come 
on  when  the  person  rises  to  micturate.  The  sudden  change 
from  a  recumbent  to  an  upright  position  lessens  the  pressure 
of  blood  in  the  cerebral  arteries,  while,  at  the  same  time,  by 
emptying  the  bladder  the  intra-abdominal  pressure  is  lessened, 
and  the  blood  is  retained  in  the  splanchnic  area.  But  the  cases 
in  which  the  heart  is  most  likely  to  be  stopped  by  digitalis  are 
those  in  which  the  arterial  pressure  is  already  high,  as  in 
advanced  Bright's  disease,  and  where  the  heart  has  already 
become  fatty.  In  such  cases  digitalis  must  be  used  with  great 
caution,  for  there  is  a  double  risk.  On  the  one  hand,  there  is 
the  danger  just  alluded  to  of  stopping  the  heart,  and  on  the 
other,  there  is  the  risk  of  causing  apoplexy  by  the  arterial 
tension  rising  so  high  as  to  burst  a  vessel  in  the  brain. 

Removal  of  these  Drawbacks  by  Combination. — Yet  in 
many  such  cases  we  sadly  want  the  steadying  and  strengthen- 
ing effect  of  digitalis  or  strophanthus  upon  the  heart,  and  we 
are  able  to  obtain  the  result  we  desire  by  combining  these 
drugs  with  others  belonging  to  an  entirely  different  class, 
namely,  that  of  vaso-dilators. 

Vaso-dilators. — The  first  vaso-dilator  investigated  was 
nitrite  of  amyl.  Its  power  of  causing  flushing  of  the  face  was 
noticed  by  Guthrie  in  1859,  and  Dr.  B.  W.  Richardson  ob- 
served that  it  caused  dilation  of  the  capillaries  in  the  frog's 
foot;  but  it  was  Dr.  Arthur  Gamgee  who  first  discovered  its 
power  of  lowering  the  blood  pressure.  It  was  under  his  direc- 
tion that  I  had  been  carrying  out  my  experiments  on  digitalis 
in  the  late  Professor  Douglas  Maclagan's  laboratory,  and  I 
used  to  submit  myself  to  Dr.  Gamgee  for  experiments  upon 
the  effect  of  nitrite  of  amyl  on  my  own  pulse,  from  which  he 
made  sphygmographic  tracings,  and  these  experiments  nat- 


164 


THERAPEUTICS    OF    THE    CIRCULATION 


urally  rendered  me  thoroughly  conversant  with  its  physio- 
logical action  on  the  pulse.     The  numerous  observations  I  had 


189.  Tracing  showing  the  ac- 
tion of  isobutyl  nitrite  on  blood  pres- 
sure. The  indications  in  the  tracing 
are  the  same  in  Fig.  190. 


FIG.  190.  Tracing  showing  the  ac- 
tion of  amyl  nitrite  on  the  blood  pres- 
sure. The  point  where  the  administra- 
tion was  begun  is  marked  by  a  cross; 
the  point  where  it  was  discontinued,  by 
a  small  arrow.  The  horizontal  double- 
headed  arrow  indicates  the  zero  point 
of  pressure;  the  single-headed  arrow  in- 
dicates the  direction  in  which  the  trac- 
ing is  to  be  read. 


made  upon  my  own  pulse1  naturally  made  me  rather  expert 
in  the  use  of  the  sphygmograph ;  and  when  resident  in  the 

1  Lauder  Brunton  on  "  Digitalis,"  Inaugural  Thesis,  1866,  and  Collected 
Papers  on  Circulation  and  Respiration,  First  Series,  pp.  129-136. 


FIRST    USE   OF   AMYL    NITRITE 


i65 


Royal  Infirmary  at  Edinburgh  I  made  a  number  of  observa- 
tions upon  a  case  of  angina  pectoris  which  was  at  that  time 
in  the  wards.  I  found  that  during  every  attack  the  tension 
of  the  pulse  became  greatly  increased,  and  as  the  pain  passed 
off  the  tension  fell.  Every  remedy  had  been  tried  in  vain, 
and  the  patient  was  just  going  out  of  the  hospital  when  it 
occurred  to  me  that  if  one  could  lower  the  pressure  in  his 
vessels  one  would  very  probably  relieve 
the  pain.  I  therefore  kept  him  in  one 
day  longer  to  try  the  experiment,  and 
promised  him  that  if  it  should  fail  he 
should  go  out  next  day.  To  my  de- 
light the  experiment  proved  a  complete 
success.  As  I  administered  the  nitrite 
of  amyl,  which  my  friend  Dr.  Gamgee 
had  given  me,  the  patient's  face  became 
flushed,  the  pulse,  instead  of  being 
small  and  thready,  became  full  and 
bounding,  and  the  pain  almost  instan- 
taneously disappeared.  (Figs.  204- 
214,  p.  190.)  Nitrite  of  amyl  still 
holds  its  place  in  medical  practice  as 
the  most  rapid  and  powerful  vascular 
dilator,  but  other  nitrites  or  nitrates 
having  a  slower  but  more  lasting  action 
have  now  come  into  more  general  use. 
In  1876,  along  with  Mr.  Tait,1  I 
discovered  that  nitroglycerine  had  an 
action  upon  the  circulation  similar  to 
that  of  nitrite  of  amyl,  but  I  used  to  get  such  an  awful  head- 
ache from  working  with  it  that  I  hesitated  to  give  it  to 
patients,  and  while  I  was  still  hesitating  Dr.  Murrell  employed 
it  in  a  case  of  angina  with  great  success.  It  has  now  be- 
come the  stock  remedy  for  lowering  arterial  tension,  and  has 
been  introduced  into  the  British  Pharmacopoeia  in  the  form 

1  St.  Bartholomew's  Hospital  Reports,  1876,  p.  144. 


FIG.  191.  Action  of 
hydroxylamine  hydrochlor- 
ate  on  blood  pressure. 


1 66  THERAPEUTICS    OF    THE    CIRCULATION 

of  tablets  containing  a  hundredth  of  a  grain  in  chocolate. 
These  may  be  either  taken  at  once,  or  a  little  bit  of  them 
may  be  nibbled  and  the  nibbling  carried  on  until  the  pain 
passes  off.  If  one  is  not  sufficient,  more  may  be  used. 
Whilst  working  in  Professor  Ludwig's  laboratory  in  1869,  I 
found  that  sodium  nitrite  had  a  similar  action  to  amyl  nitrite, 
but  not  so  marked.  This  observation  was  not  published,  and 
the  action  of  sodium  nitrite  was  described  some  years  later 
by  Dr.  Hay.  In  1876  and  1877  I  made  also  a  large  num- 
ber of  experiments,  along  with  the  late  Dr.  Gresswell  of 
Melbourne,  on  the  action  of  other  nitrites,  but  owing  to  vari- 
ous circumstances  these  results  also  have  not  been  published. 
A  very  interesting  research  by  Professors  Cash  and  Dunstan1 
on  various  nitrites  shows  that  they  are  all  alike  in  the  nature 
of  their  action,  though  differing  somewhat  in  degree.  The 
same  is  the  case  with  a  substance  differing  entirely  from  them 
chemically,  namely,  hydroxylamine,  which  Mr.  T.  J.  Boken- 
ham2  and  I  found  to  dilate  the  vessels,  and  produce  a  fall  in 
the  blood  pressure  almost  identical  with  that  caused  by  nitrite 
of  amyl. 

A  most  interesting  discussion  of  the  drugs  belonging  to  the 
nitrous  group  is  contained  in  the  lectures  of  the  late  Professor. 
Leech,  whose  death  was  a  loss  to  the  whole  scientific  world, 
and  a  great  personal  grief  to  everyone  who  knew  him.  Nitro- 
erythrol  is  another  substance  which  is  almost  more  useful  than 
any  of  the  other  nitrites,  because  its  action,  though  less 
powerful,  is  more  prolonged  than  theirs,  and  in  cases  where 
we  wish  to  keep  the  blood  pressure  constantly  low,  it  is  very 
convenient,  an  eighth  to  half  a  grain  or  even  more  being  taken 
every  two,  four,  or  six  hours,  more  or  less  as  the  case  re- 
quires. Nitromannitol  may  also  be  used  in  doses  of  one  grain 
or  more.  Where  the  pulse  is  very  quick,  aconite  or  colchicum 
may  be  given  and  general  bleeding  may  be  required. 

1  Cash  and  Dunstan. 

2Brunton  and  Bokenham,  Roy.  Soc.  Proc.,  1889,  vol.  xlv.,  p.  352. 


LECTURE   VII 

Nicotine — Tobacco  Smoking — Attractions  of  Smoking — Results  of  Ex- 
cessive Smoking — Aconite — Local  Modification  of  the  Circulation:  Inflam- 
mation— General  Bleeding — Local  Bleeding — Treatment  of  Cardiac  Dis- 
eases :  Treatment  of  Palpitation — Diet  and  Regimen — Graves's  Disease — 
Tachycardia  from  Strain — Paroxysmal  Tachycardia. 

Nicotine. — Another  drug  which  has  a  very  powerful  in- 
fluence upon  the  blood  pressure  and  cardiac  action,  is  nicotine. 
Both  in  frogs  and  mammals  nicotine  produces,  first  convul- 
sions and  then  paralysis.  When  applied  in  small  doses  to  the 
frog's  heart,  it  causes  the  beats  at  first  to  become  slow  and 
afterwards  quick.  If  the  dose  be  large,  no  primary  slowing 
may  be  observed.  In  animals  it  causes  slowing  of  the  heart, 
with  enormous  rise  of  blood  pressure.  The  rise  of  blood 
pressure  is  so  great  that  I  have  never  seen  it  equalled  after  the 
injection  of  any  drug,  with  the  exception  of  suprarenal  extract. 
The  rise  of  pressure  is  chiefly  due  to  contraction  of  the  arteri- 
oles.  This  contraction  is  partly  dependent  upon  stimulation 
of  the  vaso-motor  center  in  the  medulla  oblongata,  but  partly 
also  to  a  local  action  upon  the  arterioles  themselves,  as  it  may 
be  produced  by  injection  of  the  drug  even  after  the  medulla 
has  been  destroyed.  The  pulse-rate  in  mammals  is  first 
slowed  and  afterwards  quickened,  just  as  in  the  frog.  The 
slowing  is  due  partly  to  stimulation  of  the  vagus  center  in  the 
medulla  oblongata,  and  partly  to  the  stimulation  of  the  in- 
hibitory apparatus  in  the  heart  itself.  The  subsequent  in- 
crease in  the  pulse-rate  is  due  to  paralysis  of  these  ganglia. 
In  consequence  of  this  double  action  of  nicotine,  if  the  vagus 
be  divided  during  the  period  of  slow  pulse,  the  pulse  becomes 
somewhat  quicker,  but  still  remains  slower  than  normal. 
When,  however,  the  dose  has  been  sufficiently  large  to  quicken 
the  pulse,  no  stimulation  of  the  vagus  will  slow  the  heart,  as 
its  terminal  branches  in  the  heart  are  paralyzed  by  the  drug. 

167 


1 68  THERAPEUTICS    OF   THE    CIRCULATION 

This  action  is  the  same  in  the  heart  of  the  frog,  so  that  after 
a  large  dose  of  nicotine,  stimulation  of  the  vagus  has  no  effect 
upon  the  heart,  but  stimulation  of  the  venous  sinus  itself  will 
slow  the  heart.  The  reason  of  this  probably  is,  that,  although 
the  inhibitory  ganglia  in  the  heart  are  paralyzed,  the  inhibitory 
neurons  which  proceed  from  them  are  still  intact,  and  are 
affected  by  local  stimulation. 

Formerly,  tobacco  enemata  were  used  as  a  means  of  caus- 
ing vascular  and  general  relaxation,  but  they  were  far  from 
being  without  danger  and  are  never  employed  now.  But, 
although  tobacco  is  not  used  as  a  remedy  for  disease,  its  em- 
ployment is  so  universal  that  its  action  requires  very  careful 
consideration.  Nicotine  alone  is  only  taken  into  the  body 
when  tobacco  is  used  by  chewing  or  by  snuffing.  When  it  is 
chewed,  most  of  the  juice  is  expectorated,  but  a  small  portion 
is  probably  swallowed.  When  tobacco  is  used  in  the  form  of 
snuff,  small  quantities  of  it  find  their  way  into  the  naso- 
pharynx and  they  are  swallowed.  The  tobacco  used  for  chew- 
ing or  snuffing  contains,  as  a  rule,  but  very  little  nicotine,  and 
so  symptoms  of  poisoning  from  either  of  those  habits  are  rare. 

Tobacco  Smoking. — Usually,  tobacco  is  employed  by  smok- 
ing, either  in  the  form  of  cigars  or  cigarettes,  or  in  a  pipe. 
\Vhen  used  in  any  one  of  these  forms  it  is  not  pure  nicotine 
which  reaches  the  mouth,  but  really  the  products  of  the  dry 
distillation  of  tobacco,  containing  a  large  quantity  of  pyridine 
and  picoline  bases.1  Probably  nicotine  in  greater  or  less  quan- 
tity is  also  present.  The  proportions  of.  the  pyridine  and 
picoline  bases  in  the  tobacco  smoke  vary  according  to  the  mode 
in  which  it  is  burnt.  In  a  cigar  there  is  a  freer  access  of  air, 
so  that  much  collidine  and  little  pyridine  are  formed,  while 
in  a  pipe  much  more  pyridine  is  produced,  and  thus  stronger 
tobacco  can  be  smoked  in  a  cigar  than  in  a  pipe.  So  much  is 
this  the  case,  that  tobacco  which  in  the  form  of  a  cigar  would 
produce  no  disagreeable  effect,  may  cause  giddiness  and  vomit- 

1Vohl    and    Eulenburg,  Arch.  Pharm.    [2],  cxlvii.,  130-166.     Abstracted 
by  Lander  Bi;unton  in  Journ.  Chem.  Soc.,  1871,  New  Ser.,  vol.  ix.,  p.  1075. 


ATTRACTIONS    OF    SMOKING  169 

ing  if  smoked  in  a  pipe.  The  smoke  from  a  pipe  or  cigar 
usually  passes  simply  into  the  mouth  and  out  again,  either 
through  the  mouth  or  the  nostrils;  but  when  smoked  in  a 
huka  or  .narghileh,  the  smoke  is  inhaled  into  the  lungs,  and 
this  is  frequently  done  also  by  people  who  smoke  cigarettes. 
When  a  huka  or  a  narghileh  is  used,  the  smoke  passes  through 
water  before  being  inhaled,  and  it  is  thus  deprived  of  most  of 
its  poisonous  constituents;  but  this  is  not  so  with  the  smoke 
of  cigarettes,  and,  as  absorption  occurs  very  rapidly  from  the 
pulmonary  mucous  membrane,  cigarette  smoking  is  sometimes 
very  injurious.  There  is  another  reason,  however,  why  ciga- 
rette smoking  is  frequently  more  harmful  than  smoking  a 
pipe  or  cigar,  and  it  is  that  cigarettes  are  small  and  can  be 
smoked  in  a  few  minutes,  so  that  many  more  cigarettes  than 
pipes  or  cigars  are  consumed  in  the  course  of  the  day,  and 
the  total  quantity  of  tobacco  used  is  thus  much  greater  in  the 
form  of  cigarettes. 

Smoking  in  moderation  does  not  seem  to  be  injurious  to 
grown-up  people,  but  there  appears  to  be  a  general  consensus 
of  opinion  that  it  is  very  distinctly  harmful  to  growing  lads. 

Attractions  of  Smoking. — In  adults,  smoking  appears  to 
have  a  double  action.  It  will  stimulate  the  brain  to  increased 


FIG.    192.      Tracing  to  show  the  increased  rapidity  of  circulation  in  the  carotid  of 
horse   during  mastication.       (After   Marey.) 


activity,  and  it  will  also  produce  a  soothing  effect  in  conditions 
of  excitement.  Its  stimulating  effect  upon  mental  activity  is 
probably  partly  due  to  the  local  irritant  action  of  smoke  upon 
the  mouth,  causing  reflex  dilation  of  the  vessels  which  supply 
the  brain  in  somewhat  the  same  way  as  mastication  (Fig.  192). 


I/O  THERAPEUTICS    OF    THE    CIRCULATION 

Its  action  as  a  sedative  is  probably  partly  due  to  the  necessity 
of  breathing  rhythmically  while  smoking,  and  the  soothing 
effect  of  watching  the  smoke  as  it  issues  from  the  lips  or 
nostrils,  especially  when  it  is  blown  out  in  the  form  of  rings. 
This  is  by  no  means  an  unimportant  factor,  for  many  people 
derive  but  very  little  pleasure  from  smoking  in  the  dark. 

Results  of  Excessive  Smoking. — One  of  the  commonest 
results  of  excessive  smoking  is  chronic  pharyngitis,  with  irrita- 


FIG.  193.  Pulsations  of  the  fontanelle  (F)  in  an  infant  six  weeks  old  while  sucking. 
R  shows  a  simultaneous  tracing  of  the  thoracic  respiration.  The  breast  was  offered 
to  the  child  at  the  beginning  of  the  tracing.  At  the  time  indicated  by  the  third 
respiratory  wave,  which  has  a  flattened  top,  the  child  began  to  take  the  breast.  It 
will  be  noticed  that  the  line  of  the  tracing  F  rises,  indicating  increased  circulation 
on  the  brain.  (After  Salathe.) 

bility  of  the  throat,  cough  and  hoarseness,  and  sometimes  the 
irritation  also  affects  the  tongue.  Weakness  of  vision,  nervous 
tremor,  and  giddiness  frequently  result  from  tobacco-smoking. 
It  is  difficult  to  decide  how  far  these  are  due  to  the  direct  action 
of  the  tobacco  smoke  upon  the  nervous  system,  and  how  far 
they  are  caused  through  alteration  in  the  circulation.  The 
circulation  becomes  much  affected ;  palpitation  and  pain  in  the 
cardiac  region  are  common  results.  Sometimes,  though  rarely, 
the  cardiac  pain  may  be  so  great  as  to  simulate  angina  pectoris. 
Irregularity  of  the  heart  is  very  common,  and  it  appears  to  me 
that  this  irregularity  is  more  frequently  found  from  a  common 
kind  of  tobacco  known  as  "  pig-tail  "  than  from  better-class 
tobaccos.  When  I  was  a  house  physician  I  met  with  it  very 
frequently,  and  the  cardiac  rhythm  might  be  represented  some- 
what in  this  way : 


ACONITE  I  / 1 

a  pause,  followed  by  one  or  two  heavy  beats,  then  a  succession 
of  quick,  small  beats,  and  then  a  pause  again.  With  better- 
class  tobaccos  I  have  not  observed  this  irregularity  so  fre- 
quently, but  I  have  more  often  seen  the  patient  simply  fall 
down  unconscious,  as  if  he  had  been  shot.  These  unpleasant 
symptoms,  as  well  as  the  nervous  symptoms  which  accompany 
them,  may  sometimes  cease  upon  lessening  the  amount  of 
tobacco  used,  but  not  un frequently  a  very  small  quantity 
appears  to  keep  up  the  condition  after  it  has  once  been  es- 
tablished :  and  complete  abstinence  from  tobacco,  occasionally 
for  a  period  of  several  months,  is  required  before  it  can  be 
resumed  without  causing  a  recurrence  of  the  symptoms. 

Aconite. — Aconite  is  a  drug  which  may  be  looked  upon  as 
a  typical  cardiac  depressant.  Its  most  characteristic  physio- 
logical action  is  that  of  causing  numbness  and  tingling  when 
applied  to  the  tongue  in  small  quantities,  and  this  test  is  much 
more  delicate  than  any  chemical  reaction.  When  adminis- 
tered to  mammals  in  small  doses,  it  slows  the  heart  very 
greatly,  and  this  effect  is  entirely  due  to  its  action  upon  the 
vagus  center.  Its  effects  are  precisely  similar  to  those  pro- 
duced by  stimulation  of  the  vagus,  the  heart  being  rendered 
slow  and  the  blood  pressure  falling.  In  larger  doses  it  para- 
lyzes the  ends  of  the  vagus  in  the  heart,  so  that  the  pulse 
becomes  suddenly  very  rapid  and  at  the  same  time  irregular. 
It  appears  to  have  also  a  local  action  on  the  cardiac  muscle, 
but  this  is  of  a  very  complex  nature,  and  is  probably  con- 
nected with  stimulation  and  paralysis  of  some  sensory  mechan- 
ism in  the  heart  itself,  to  which  the  cardiac  pulsations  are 
partly  due.  That  such  a  reflex  mechanism  actually  exists  in 
the  heart  itself  appears  to  be  shown,  amongst  other  things,  by 
the  experiments  of  Von  Basch  and  A.  Frohlich1  upon  the  ac- 
tion of  cocaine  on  the  heart.  They  found  that  when  the  sur- 
face of  the  heart  was  stimulated  by  a  Faradic  current,  which 
caused  an  extra  beat  and  compensatory  pause,  this  effect 

1  Von  Basch  and  A.  Frohlich,  Centralblatt  fiir  Physiologic,  Band  xviii. ; 
Literatur,  1904,  p.  693. 


172 


THERAPEUTICS    OF    THE    CIRCULATION 


diminished  rapidly  when  cocaine  was  applied  to  the  surface 
of  the  heart.  This  action  was  not  due  to  any  effect  of  cocaine 
upon  the  cardiac  muscle,  but  only  to  its  local  action  on  the 
epicardium.  It  is  not  improbable  that  the  effect  of  aconite 
upon  the  heart  may  be  due  to  an  action  upon  the  sensory 
mechanism  in  it  somewhat  analogous  to  that  of  cocaine.  One 
effect  of  aconite  is  to  disturb  the  rhythm  very  greatly,  so  that 


foSD MOTOR  CENTRE 
/N  MEDULLA. 


VASO  MOTOR 
FOR  THE  VESSELS 
OF  THE  EAR 


ASO  MOTOR  NERVES 
)     FOR  OTHER  PARTS 
OF  THE  BODY 


FIG.   194.      Diagram  of  the  vaso-inotor  nerves  of  the  rabbit's  ear. 

in  the  frog's  heart  the  normal  beats  and  peristaltic  action  may 
alternate. 

The  chief  use  of  aconite  is  in  local  inflammations  accom- 
panied by  general  febrile  disturbance.  Small  doses  of  this  drug 
appear  occasionally  to  be  exceedingly  useful ;  for  example,  in 
tonsillitis  and  in  febrile  colds.  In  nervous  flutterings  of  the 
heart,  aconite  in  small  doses  appears  to  quiet  the  circulation, 
but  how  it  does  so  I  cannot  at  present  explain.  Very  small 


USES    OF    ACONITE 


173 


FIG.   195.       Blood  vessels  in  normal  condition.       (After  Lister.) 


FIG.    196.      Same  vessels  after  the   application  of  an  irritant  and   commencement  of 
inflammation.       (After    Lister.) 


174  THERAPEUTICS.  OF    THE    CIRCULATION 

doses  are  sufficient,  and  often  seem  to  slow  the  pulse  more  than 
larger  ones.  One  minim  of  the  pharmacopoeial  tincture  every 
hour  is  frequently  sufficient,  although  the  dose  given  in  the 
British  Pharmacopoeia  is  2  to  5  minims,  frequently  repeated,  or 
5  to  15  minims  when  given  at  longer  intervals.  In  cases  of 
persistent  high  tension  with  attacks  of  angina  pectoris,  aconite 
is  sometimes  useful.  Its  action  should  be  regulated  by  a 
sphygmomanometer. 

Local  Modification  of  the  Circulation — inflammation.— 
We  have  various  methods  of  modifying  the  circulation  locally. 
In  local  inflammations,  as  I  have  just  said,  aconite  seems  to  be 
useful,  and  during  its  administration  the  local  inflammation 
frequently  subsides,  the  pain  disappearing,  the  redness,  swell- 
ing, and  heat  of  the  part  diminishing.  We  may  modify  the 
local  circulation  in  inflammation  either  by  heat  or  cold.  If 


FIG.  197.  Diagram  to  show  the  effects  of  heat  and  cold  in  lessening  the  pain  of 
inflammation.  The  diagram  is  supposed  to  represent  the  end  of  the  ringer.  The 
small  star  indicates  the  point  of  irritation,  e.  g.,  a  prick  by  a  thorn.  The  line  in 
the  center  of  each  figure  is  intended  to  represent  the  nerve  going  to  the  injured  part; 
and  at  the  side  of  each  figure  is  an  artery  and  vein  connected  by  a  capillary  network. 
In  a  the  capillary  network  around  the  seat  of  irritation  is  seen  to  be  much  congested; 
the  nerve-filaments  are  thus  pressed  upon,  and  pain  is  occasioned;  b  represents  the 
condition  of  the  finger  after  the  application  of  cold  to  the  arm  or  hand.  In  con- 
sequence of  the  contraction  of  the  afferent  arteries  the  finger  becomes  ansmic;  no 
pressure  is  exerted  on  the  nervous  filaments,  and  pain  is  alleviated;  c  represents  the 
finger  after  it  has  been  encased  in  a  warm  poultice;  the  capillary  network  at  the 
surface  of  the  finger  is  dilated,  and  the  blood  is  thus  drawn  away  from  the  seat  of 
irritation,  and  the  pain  therefore  relieved. 

the  inflammation  be  situated  in  a  place  where  the  tissues  are 
yielding,  heat  frequently  relieves  it  most,  but  if  the  tissues  are 
unyielding,  as,  for  example,  where  the  inflammation  occurs  at 
the  root  of  a  tooth  or  under  a  hard  fascia,  heat  increases  the 


LOCAL    MODIFICATION    OF    THE    CIRCULATION 

pain  while  cold  relieves  it.  The  explanation  of  this  is  obvious. 
Heat  tends  to  cause  local  dilation  of  the  vessels,  and  if  the 
nerves  which  run  alongside  them  are  in  an  unyielding  sheath, 
the  dilated  vessels  press  more  upon  them  and  increase  the 
pain;  whereas  if  the  tissues  are  yielding  all  round,  the  col- 
lateral circulation  is  increased,  and  the  pressure  of  blood  in 
the  inflamed  area  is  lessened.  If  the  nerves  and  vessels  are 
both  confined  in  an  unyielding  sheath,  the  application  of  cold 
tends  to  cause  contraction  of  the  vessels,  and,  by  diminishing 
their  caliber,  to  lessen  pressure  upon  the  nerves  and  ease  the 
pain.  The  local  application  of  heat  may  induce  a  pretty  ex- 
tensive dilatation  of  the  vesels;  for,  on  putting  my  feet  into 
a  bath  of  hot  water,  I  have  sometimes  observed  increased 
pulsation  of  the  femoral  arteries.  The  local  application  of 
cold  in  the  case  of  an  artery  will  cause  it  to  contract,  and 
lessen  the  circulation  in  the  distal  part;  so  that  if  a  cold  band- 
age be  applied  over  the  middle  of  the  arm,  the  radial  artery 
will  beat  less  strongly.  By  putting  on  a  cold  bandage  covered 
with  oil-silk  a  gentle  warmth  of  the  surface  is  produced,  which 
seems  to  have  a  quieting  effect  upon  the  circulation  and  lessens 
the  pain  from  inflammation,  as  is  evident  from  its  use  in 
various  local  lesions,  and  perhaps  most  markedly  when  ap- 
plied to  the  throat  in  cases  of  pharyngitis  and  tonsillitis.  A 
large  wet  compress  of  this  sort  applied  to  the  abdomen  is 
sometimes  very  useful  in  cases  of  sleeplessness,  as  it  tends 
to  draw  away  the  blood  from  the  brain  and  allow  the  nerve 
cells  to  become  quiet.  Warmth  to  the  inside  of  the  stomach 
has  a  similar  action,  and  warm  food  will  often  tend  to  pro- 
duce sleep.  The  food  must,  however,  not  be  too  warm,  as 
otherwise  the  heat  will  pass  through  the  diaphragm,  and  by  its 
local  stimulating  action  on  the  heart  will  increase  the  force  of 
the  pulse,  and  by  driving  more  blood  to  the  brain,  lessen  the 
tendency  to  sleep  instead  of  increasing  it. 

General  Bleeding. — Bleeding  from  the  arm  is  a  remedy 
which  is  now  too  little  used.  In  the  case  of  angina  pectoris, 
in  which  I  used  nitrite  of  amyl  for  the  first  time,  small  bleed- 


THERAPEUTICS    OF    THE    CIRCULATION 


Vessels  of  thoracic  wall 


FIG.  198. 


Vaso-motor  centre. 


Vessels  of  body  generally. 


Dilated  vessels  of  lung. 


Diagram  to  show  congestion  of  the  lung.     The  pulmonary  vessels  are  shown 
dilated,   and  those  of  the  thoracic  wall  contracted. 


Dilated  vessels  of 
thoracic  wall — 


Blister 


Vaso-motor  centre. 


Vessels    of   body 
generally. 


Contracted  vessels 
of  lung. 


FIG.  199.  Diagram  to  explain  the  action  of  counter-irritation.  A  blister  or  other 
counter-irritant  is  shown  applied  to  the  chest-wall.  The  stimulus  which  it  causes  is 
transmitted  up  the  afferent  nerves  to  the  vaso-motor  center;  it  is  thence  reflected  down 
the  vaso-motor  nerves  to  the  pulmonary  vessels,  causing  them  to  contract,  while  it  is 
reflected  down  vaso-dilating  fibers  to  the  vessels  of  the  thoracic  wall,  and  probably  of 
other  parts  of  the  body  also,  causing  them  to  dilate,  and  thus  lessening  the  pulmonary 
congestion  by  withdrawing  blood  from  the  lungs.  (Compare  with  Fig.  198.) 


FIG.  200.  Showing  the  effect  of  cold  upon  the  arteries.  A  shows  the  normal 
sphygmogram  from  the  radial  artery.  B  is  the  same  after  the  application  of  a  cold 
compress  above  the  elbow.  (After  Winfernitz.) 


LOCAL    BLEEDING  177 

ings  of  three  or  four  ounces  were  the  only  thing  which  eased 
the  pain  before  the  nitrite  was  employed,  and  even  after  its 
employment  bleeding  from  the  arm  benefited  the  patient.1 
In  engorged  conditions  of  the  right  side  of  the  heart,  whether 
due  to  mitral  incompetence  or  pulmonary  affections,  blood- 
letting not  only  relieves  the  symptoms,  but  may  save  the 
patient's  life. 

Local  Bleeding. — A  means  of  influencing  the  circulation 
locally,  which  was  formerly  much  employed,  but  has  now  to  a 
great  extent  fallen  into  disuse,  is  the  application  of  leeches 
and  cupping.  The  relief  which  is  obtained  by  the  application 
of  half  a  dozen  leeches  to  the  side,  in  cases  of  severe  pleurisy, 
is  very  extraordinary;  and  it  is  difficult  indeed  to  see  how 
the  comparatively  small  quantity  of  blood  which  they  extract 
should  relieve  the  patient  so  much,  but  there  can  be  no  doubt 
about  the  fact  that  the  relief  they  afford  is  enormous.  Their 
application  over  the  mastoid  process  in  severe  headache  or  in 
meningitis,  and  over  the  cardiac  area  in  pericarditis  or  the 
liver  in  hepatitis,  especially  if  accompanied  with  perihepatitis, 
is  very  useful.  Wet  cupping  over  the  kidneys  in  acute 
nephritis  and  over  the  back  in  suffocative  bronchitis,  is 
sometimes  attended  with  marked  amelioration  of  the  symp- 
toms. It  is  not  simply  the  removal  of  blood  that  produces 
this  effect,  because  dry  cupping,  where  no  blood  is  removed, 
is  frequently  of  service.  In  dry  cupping  the  beneficial  result 
may  be  partly  due  to  the  withdrawal  of  blood  to  the  skin  and 
subcutaneous  tissue.  It  may  also  be  due  to  a  reflex  effect  of 
the  stimulus  upon  the  circulation,  both  local  and  general,  and 
it  may  possibly  be,  to  some  extent,  a  form  of  serum  therapeu- 
tics, as  the  fluid  which  exudes  into  the  tissues  after  the  appli- 
cation of  the  cups  may  undergo  some  alteration  which  imparts 
to  it  a  curative  action  after  its  reabsorption.  Any  explanation 
of  the  mode  of  action,  however,  is  at  present  hypothetical,  and 
we  are  obliged  to  be  content  with  knowing  what  the  effects  are 

1Lauder  Brunton,  Clinical  Society  Reports,  vol.  Hi.,  1870;  and,  Collected 

Papers,  First  Series,  p.  186. 

13 


1/8  THERAPEUTICS    OF    THE    CIRCULATION 

without  understanding  how  they  are  produced.  The  same 
may  be  said  of  the  marked  benefit  which  results  from  local 
applications  over  the  cardiac  region.  When  the  heart  is  ex- 
cited by  emotion,  the  natural  tendency  is  to  place  the  hand 
over  the  heart,  in  order,  as  the  phrase  goes,  "  to  still  its  beat- 
ing." The  pressure  of  the  hand  over  the  cardiac  region  cer- 
tainly tends  to  quiet  palpitation,  and  the  same  result  is  ob- 
tained, even  to  a  greater  extent,  by  permanent  pressure  from 
the  application  of  a  plaster  over  this  region.  The  plaster  may 
be  simply  adhesive;  but  I  think  the  use  of  extract  of  bella- 
donna is  something  more  than  a  prejudice,  and  a  belladonna 
plaster,  I  think,  really  has  a  more  powerful  action  as  a  cardiac 
sedative  than  a  merely  adhesive  plaster.  A  good  deal  depends 
upon  the  way  the  plaster  is  applied.  It  is  best  not  to  have  it 
too  small,  and  in  the  case  of  women  it  ought  to  be  cut  like 
the  pattern  which  I  show  you,  so  that  it  may  fit 
over  the  breast.  An  india-rubber  bag,  filled  with 
crushed  ice,  applied  over  the  cardiac  region  some- 
times quiets  excessive  cardiac  action ;  or,  in  place 
of  it,  a  tube  of  india-rubber,  coiled  round  and  round,  so  as  to 
form  a  flat  plate  through  which  cold  water  may  be  passed  in 
a  continuous  stream,  may  have  a  similar  action.  When  the 
action  of  the  heart  is  feeble,  a  bag  filled  with  hot  water,  or  a 
warm  poultice,  a  warm  fomentation,  or  a  turpentine  stupe,  may 
stimulate  its  action.  In  one  case  of  cardiac  disease  I  have 
seen  ammonia  liniment  rubbed  over  the  cardiac  region  for  the 
relief  of  pain  bring  on  such  palpitation  as  to  cause  very  great 
inconvenience  to  the  patient,  and  to  necessitate  the  relinquish- 
ing of  the  remedy. 

TREATMENT  OF  CARDIAC  DISEASES 

Treatment  of  Palpitation. — We  may  pass  now  from  the 
consideration  of  the  therapeutic  means  at  our  disposal  to  the 
treatment  of  definite  disorders  of  the  circulation.  First  of  all, 
we  may  take  palpitation.  The  first  thing  to  be  done  is,  of 
course,  to  try  and  find  out  its  cause,  and  relieve  it  if  possible. 


TREATMENT    OF    PALPITATION 

In  cases  where  it  depends  upon  the  excessive  use  of  alcohol, 
tobacco,  tea,  or  coffee,  these  articles  should  either  be  dimin- 
ished or,  if  necessary,  cut  off  entirely.  The  use  of  a  bella- 
donna plaster  I  have  already  mentioned,  and  here  the  distinc- 
tion between  gentle,  steady  pressure  and  hard  pressure  is  ob- 
vious, because,  although  the  slight  pressure  of  the  plaster  or 


RECTUM    AND    H^EMORRHOIDAL    PLEXUS. 


FIG.  201.  Diagram  of  the  veins  forming  part  of  the  portal  circulation.  The 
pancreatic  and  splenic  veins,  although  most  important,  have  been  omitted  for  the  sake 
of  clearness. 

hand  tends  to  quiet  the  heart,  yet  the  harder  pressure  pro- 
duced by  lying  upon  the  left  side  frequently  aggravates  the 
palpitation,  so  that  patients  are  obliged  to  lie  upon  the  right 


ISO  THERAPEUTICS   OF   THE    CIRCULATION 

side.  In  some  cases  they  are  obliged  to  lie  upon  their  back ; 
but,  as  a  rule,  lying  on  the  back  is  disadvantageous.  In  many 
people  it  appears  to  disturb  the  circulation  to  such  an  extent 
as  to  cause  a  nightmare,  frequently  of  such  a  kind  as  to  indi- 
cate interference  with  the  circulation  through  the  lungs,  be- 
cause the  dream  which  makes  the  patient  awaken  is  that  of 
being  chased  by  an  animal  or  subjected  to  some  other  sudden 
strain,  and  when  he  does  awake  he  has  the  same  sensation  of 
oppression,  and  his  heart  is  beating  just  as  if  he  had  been 
running  away  from  a  mad  bull  or  undergoing  some  other  vio- 
lent exertion. 

When  palpitation  depends  upon  distension  of  the  stomach 
by  flatulence  pushing  the  heart  up,  and  thus  bringing  its  apex 
against  the  chest  wall,  immediate  relief  is  afforded  by  carmina- 
tives to  bring  the  flatulence  away,  and  I  give  here  two  pre- 
scriptions, which  may  serve  as  examples : 

$     Sodii    Bicarb gr.  v 

Spt.  .Ether  Co HI  v 

Spt.  Chlorof niv 

Tinct.  Cardamom.  Co TTl  x 

Aq.  Menth.  Pip ad  Jj 

M.  mitte  3viij 

Sig.    One-eighth  part  to  be  taken  alone,  or  with  water,  every  ten  or  fif- 
teen minutes  until  the  flatulence  is  relieved. 

$     Spt.  Ammon.  Aromat Tl  xv 

Spt.   Chlorof ni  x 

Tinct.   Carminativ Til  x 

Aqua    ad  3ss 

M.  mitte  3VJ 

Sig.    One-twelfth  part  to  be  taken  alone,  or  in  water,  every  few  minutes 
until  the  flatulence  is  relieved. 

Another  useful  plan  is  to  give  about  one-third  of  a  tea- 
spoonful  of  sodium  bicarbonate  in  a  claret  glassful  of  water 
or  peppermint  water,  and  to  let  the  patient  slowly  sip  as 
much  of  this  as  is  necessary.  But,  in  order  to  relieve  the 
palpitation  permanently,  the  digestion  must  be  put  right  and 
fermentation  in  the  stomach  stopped.  We  must  remember 
here  that  the  blood  from  the  stomach  has  to  pass  through  the 


FLATULENCE    IN    HEART    DISEASE  l8l 

liver  (Fig.  181,  p.  154)  before  it  reaches  the  general  circula- 
tion, and  that  the  liver  and  bowels  require  attention  as  well 
as  the  stomach.  We  very  frequently  are  able  to  relieve  palpi- 
tation far  more  by  medicines  which  act  only  on  the  digestive 
canal,  than  by  drugs  which  affect  the  heart  and  vessels  directly. 
One  of  the  best  remedies  that  I  know  for  functional  irritation 
of  the  heart  is  one  which  my  old  teacher,  Dr.  Warburton 
Begbie,  used  to  call  the  "  pulvis  mirabilis."  Its  composition 
was  as  follows : 

IJ     Bismuth  Subnit gr.  x 

Sodii  Bicarb gr.  x 

Pulv.  Nuc.  Vom gr.  ss-jss 

Pulv.   Rhei gr.  j-iij 

Pulv.  Cinnamom.  Co gr.  iij 

M.  ft.  pulv. 

The  great  disadvantage  of  this  powder  was  its  filthy  taste, 
but  this  can  be  got  over  by  putting  the  nux  vomica  and 
rhubarb  in  a  cachet,  and  giving  the  other  ingredients  in  a 
mixture,  along  with  some  carminative  and  flavoring  sub- 
stance. Both  the  mixture  and  cachet  are  taken  at  the  same 
time,  and,  as  they  mix  in  the  stomach,  one  gets  the  effect  one 
desires  without  the  patient  perceiving  the  taste.  When  the 
heart  is  feeble,  three  or  four  minims  of  tincture  of  strophan- 
thus  or  of  digitalis  may  be  added  to  the  mixture  with  advan- 
tage; and  if  the  patient  be  anaemic,  some  preparation  of  iron 
may  be  either  given  along  with,  or  separate  from  the  medicine. 
Diet  and  Regimen. — Of  course,  a  large  quantity  of  food 
which  would  distend  the  stomach  mechanically  should  be 
avoided;  and,  if  required,  the  meals  should  be  small  in  quan- 
tity and  more  frequently  repeated.  Articles  of  diet  that  tend 
to  cause  flatulency,  such  as  cabbage,  pastry,  and  sugar,  should 
also  be  avoided,  or  anything  else  that  seems  to  disagree  with 
the  patient.  The  eating  must  be  slow,  and  mastication 
thorough.  In  addition  to  the  nature  of  the  food,  the  manner 
in  which  solids  and  liquids  are  taken  must  be  carefully  attended 
to.  When  much  fluid  is  drunk  with  a  meal  it  tends  to  dilute 


1 82  THERAPEUTICS    OF    THE    CIRCULATION 

the  gastric  juice,  and  this  lessens  digestion  in  the  stomach,  so 
that  digestion  must  be  finished  in  the  intestine.  When  little 
fluid  is  taken  with  a  meal  the  digestion  in  the  stomach  is  more 
perfect,  and  consequently  less  digestion  requires  to  be  carried 
on  in  the  intestine.  People  who  have  a  tendency  to  flatulence 
should  therefore  take  little  or  no  liquid  with  their  meals.  But, 
it  is  evident  that  as  the  body  contains  so  much  water,  water 
must  be  taken  in  some  form  or  another  during  the  day.  The 
best  form  in  which  to  take  it  is  that  of  simple  hot  water,  as 
hot  as  can  be  comfortably  drunk,  with  a  slice  of  lemon  floating 
on  the  surface  to  relieve  the  insipidity  of  the  hot  water  itself. 
The  water  should  not  be  drunk  in  large  draughts,  but  should 
be  slowly  sipped.  The  best  time  for  taking  the  water  is  when 
digestion  in  the  stomach  is  finished,  that  is  to  say,  three  or 
four  hours  after  a  meal.  Thus,  if  breakfast  be  taken  at  8, 
some  hot  water  may  be  sipped  between  n  and  12.  If  lunch 
be  taken  at  I  some  hot  water  may  be  sipped  between  4  and  5. 

At  this  time  the  water  may  be  either  sipped  alone  or  it  may 
be  slightly  flavored  with  tea,  or  the  water  may  be  sipped  first 
and  a  cup  of  ordinary  tea  drunk  afterwards.  The  water  alone 
is  best,  because  the  cup  of  tea  sometimes  gives  rise  to  acidity 
and  flatulence ;  but  its  refreshing  power  is  so  great  that  in  some 
cases  it  may  be  allowed,  and  if  so,  it  ought  to  be  China  tea. 
If  hot  water  or  tea  be  disliked,  the  water  may  be  simply 
flavored  with  some  kind  of  meat  extract,  or  thin  broth,  juli- 
enne soup,  or  beef-,  mutton-,  or  chicken-tea  may  be  substituted, 
but  it  must  not  be  strong.  Water  should  again  be  sipped  be- 
fore going  to  bed. 

Water  taken  in  this  way  not  only  supplies  the  needs  of  the 
body,  but  it  tends  to  wash  the  contents  of  the  stomach  out 
after  each  meal,  so  that  no  food  is  left  behind  to  ferment. 
When  the  stomach  is  not  cleaned  out,  remnants  of  food  are  apt 
to  undergo  fermentation,  and  the  portion  of  each  meal  that  is 
left  behind  tends  to  start  fermentation  in  the  next  meal,  so 
that  a  state  of  indigestion  is  set  up  which  may  remain  for  a 
length  of  time. 


USES    OF    WATER WHEN    TO    TAKE    IT  183 

In  order  that  digestion  should  be  perfect  the  food  must  be 
thoroughly  broken  up,  as  otherwise  it  will  not  be  dissolved  by 
the  gastric  juice.  Many  people  are  apt  to  chew  their  food  very 
imperfectly  and  wash  it  down  with  liquid,  either  water,  tea, 
coffee,  wine,  or  spirits,  during  the  meal.  When  no  liquid  is 
taken  with  the  meal,  this  becomes  almost  impossible.  The 
food  must  then  be  broken  up  thoroughly  and  mixed  with 
saliva.  One  great  rule  in  indigestion  of  all  sorts,  therefore,  is 
to  take  no  liquid  during  meals.  When  liquid  is  drunk  towards 
the  end  of  a  meal,  the  danger  of  imperfect  mastication  is 
lessened,  but  much  liquid  taken  at  this  time  will  still  interfere 
with  digestion  in  the  stomach,  by  diluting  the  gastric  juice  and 
so  weakening  its  digestive  power.  If  the  patient  is  able  to  take 
exercise,  a  moderate  amount  of  gentle  exercise  in  the  open 
air  is  advisable;  and  where  the  patient  seems  too  weak  for 
much  exercise,  massage  may  take  its  place  to  a  considerable 
extent.  If  other  means  fail  and  the  palpitation  is  very  dis- 
tressing, the  patient  may  be  put  to  bed  and  kept  there  steadily 
• — regular  Weir  Mitchell  treatment,  in  fact,  being  adopted. 

Palpitation  is  very  apt  to  be  associated  with  some  disturb- 
ance in  the  pelvic  organs,  and  anything  wrong  with  these  ought 
to  be  attended  to,  and  any  excitement  of  them  should  be  care- 
fully avoided. 

In  cases  where  palpitation  is  associated  with  debility, 
strychnine  or  nux  vomica  is  of  great  service,  and  may  be  given 
as  in  the  prescription  for  the  "  pulvis  mirabilis,"  shortly  before 
or  after  meals.  Its  action  is  complex,  because  it  affects  the 
whole  nervous  system,  stimulating  the  brain,  the  medulla,  and 
the  heart.  In  most  cases  it  can  be  borne  even  in  large  doses, 
but  there  are  some  where  it  does  harm  rather  than  good,  more 
especially  in  patients  of  a  highly  nervous  temperament,  and 
where  there  is  a  tendency  to  excessive  sensibility  of  the  pelvic 
organs. 

Graves's  Disease. — In  Graves's  disease  we  frequently  meet 
with  very  considerable  palpitation,  associated  with  excessive 
rapidity  of  the  heart,  and  sometimes  we  find  these  conditions 


184  THERAPEUTICS    OF    THE    CIRCULATION 

present  without  any  protrusion  of  the  eyeballs.  As  I  men- 
tioned before,  palpitation  may  be  caused  by  a  too  prolonged 
administration  of  thyroid  gland.  The  best  treatment  for 
Graves's  disease  is  undoubtedly  prolonged  rest  in  bed,  and  one 
of  the  most  successful  cases  I  ever  had  was  a  lady  who,  luckily, 
became  pregnant  shortly  after  the  onset  of  the  disease.  She 
was  kept  constantly  in  bed  for  nine  months,  and  made  a  per- 
fect recovery.  As  such  patients  are  usually  very  emotional, 
bromides  of  potassium,  sodium,  ammonium,  or  strontium, 
either  singly  or  combined,  are  often  beneficial,  quieting  the 
nervous  irritability  and  removing  the  restlessness  and  sleep- 
lessness which  sometimes  are  present.  I  have  frequently  used, 
and  I  think  with  benefit,  calcium  chloride,  and  suprarenal  ex- 
tract. Kocher  thinks  that  phosphates  should  be  given  freely.1 

Tachycardia  from  Strain. — Excessive  exercise  appears  to 
be  sometimes  followed  by  a  rapid  action  of  the  heart,  which, 
instead  of  passing  after  the  exercise  is  over,  may  continue  for 
days  or  even  weeks.  In  all  probability  such  cases  are  due  to  a 
certain  amount  of  cardiac  strain,  and  ought  to  be  treated  as 
such. 

Paroxysmal  Tachycardia. — In  paroxysmal  tachycardia, 
the  beats  of  the  heart,  which  may  previously  have  been  per- 
fectly normal,  suddenly  become  excessively  rapid,  as  much  as 
three  or  four  times  as  quick  as  before.  It  would  almost  seem 
in  these  cases  as  if  each  cavity  of  the  heart  was  capable  of 
giving  an  independent  stimulus  to  the  contraction  of  the  whole, 
so  that  a  pulse  of  60  might  suddenly  jump  up  to  a  pulse  of  240. 
We  do  not  know  the  pathology  of  such  cases,  but  they  are  not 
unfrequently  associated  with  a  certain  amount  of  fatty  degen- 
eration in  the  heart.  They  are  benefited  during  the  attack  by 
cold  applications  over  the  heart,  sometimes  by  drinking  iced 
water,  so  as  to  get  the  effect  of  cold  directly  upon  the  heart 
through  the  stomach,  and  sometimes  by  a  powerful  stimulant 
such  as  strong  coffee.  The  attack  may  sometimes  be  cut 
short  by  the  administration  of  an  emetic  such  as  20  grains  of 

1  Common  salt  in  drachm  doses,  with  plenty  water,  three  times  a  day, 
is  sometimes  useful. 


PAROXYSMAL  TACHYCARDIA 


I85 


sulphate  of  zinc,  or  mustard  and  water  may  be  employed. 
During  the  interval,  small  doses  of  strophanthus,  digitalis, 
strychnine,  and  eserine  may  be  useful  in  steadying  the  heart. 
If  they  are  associated  with  high  tension,  vascular  dilators  must 
be  employed ;  and  if  they  occur  in  gouty  people,  the  diet  should 
be,  to  a  great  extent,  non-nitrogenous.  In  some  cases  the 


FIG.  202.       Case  of  exophthalmic  goitre,   St.  Bartholomew's  Hospital  Journal, 
December,   1897. 

attack  of  tachycardia  appears  to  be  due  to  reflex  irritation 
from  the  stomach,  and  bismuth,  sodium  bicarbonate,  pepsin,  or 
other  digestive  ferments  are  of  service  by  lessening  dyspepsia, 
while  bromides  diminish  reflex  irritability,  and  dilute  hydro- 
cyanic acid  acts  as  a  local  gastric  sedative. 


LECTURE  VIII 

Bradycardia — Stokes-Adams  Syndrome — Irregularity  of  Pulse — Angina 
Pectoris — Treatment  of  an  Attack  of  Angina  Pectoris — Diet  and  Regimen 
in  Angina — Cardiac  Asthma — Sleeplessness — Aortic  Disease — Mitral  Re- 
gurgitation — Nauheim  Treatment — Oertel's  Treatment — Treatment  of 
Venous  Stasis — Graduated  Exercises — Elimination — Milk  Diet — Chloride- 
free  Food — Tapping — Surgical  Treatment  of  Cardiac  Diseases — Senile 
Rise  of  Pressure — Senile  Decay — Prolongation  of  Life. 

Bradycardia. — The  opposite  of  tachycardia  is  brachycardia, 
or,  as  it  is  often  termed,  bradycardia.  In  some  cases  of  brachy- 
cardia the  slow  pulse  is  associated  with  syncope.  This  con- 
dition is  known  by  the  name  of  Stokes-Adams  syndrome.  In 
these  cases  the  patient  is  affected  sometimes  as  much  as  three 
or  four  times  a  day  by  giddiness,  insensibility,  or  epilepsy,  and 
this  condition  is  probably  due  to  atheroma  of  the  vessels  in  the 
medulla.  In  some  people  the  pulse  is  naturally  very  slow. 
In  Napoleon,  as  I  have  remarked,  it  was  said  to  have  been 
only  40  per  minute,  and  in  a  fellow-student  of  mine  was  only 
42  per  minute.  This  man  came  from  Demerara,  and  I  do  not 
know  whether  malarial  affection  had  anything  whatever  to  do 
with  it  or  not.  Extreme  slowness  of  the  pulse  is  probably  due 
to  excessive  action  of  the  inhibitory  nervous  mechanism,  either 
in  the  medulla  oblongata  or  in  the  heart  itself.  Sometimes 
the  latter  may  be  excited  by  irritation  of  the  vagus  trunks  or 
branches  of  the  vagus  in  the  cardiac  plexus,  just  as  slowness 
of  the  pulse  may  be  produced  experimentally  by  irritation  of 
the  vagus  in  animals.  Slowness  of  the  pulse  sometimes  occurs 
in  women  after  childbirth,  but  the  explanation  of  it  is  un- 
certain. It  is  very  apt  to  occur  when  the  heart  is  feeble,  as 
during  convalescence  from  infective  diseases  such  as  acute 
rheumatism,  diphtheria,  pneumonia,  and  typhoid  fever ;  in  gen- 
eral weakness  due  to  anaemia,  chlorosis,  and  diabetes;  and  in 
permanent  weakness  of  the  cardiac  walls  due  to  fatty  or  fibroid 

1 86 


BRADYCARDIA 


18; 


degeneration.  It  is  seen  also  in  typhoid  fever  even  while  the 
temperature  is  high,  and  in  this  case  it  is  probably  due  to  the 
effect  of  a  toxin  which  stimulates  the  inhibitory  mechanism 
either  in  the  medulla  or  the  heart,  and  prevents  the  pulse 
from  rising  above  96  even  when  the  temperature  would  lead 


<, -CEREBELLUM 
T"/- -'MEDULLA 
\     /    OELONCATA 


-AFFERENT 
NERVES 


INTESTINAL 
VESSELS 


FIG.  203.  Diagram  to  show  the  nervous  mechanism  by  which  the  action  of  the 
heart  may  be  depressed  by  irritation  of  the  stomach.  The  reflex  irritation  of  the 
vagus  may  render  the  heart's  action  simply  weak,  or  slow  and  weak. 

one  to  expect  a  pulse  of  120.  In  the  convalescence  from  diph- 
theria the  slowness  of  the  pulse  is  not  improbably  due  to  some 
neuritis  of  the  vagus,  which,  in  severe  cases,  leads  to  complete 
paralysis  with  exceedingly  rapid  pulse.  Other  poisons,  such 
as  those  which  occur  in  uraemia,  and  also  alcohol,  coffee,  digi- 
talis, lead,  and  tobacco,  may  cause  a  very  slow  pulse.  It  is 
frequent  in  jaundice,  and  its  occurrence  here  appears  to  be 
due  to  the  bile  acids  which  weaken  the  cardiac  muscle  and 
render  it  more  easily  affected  by  the  inhibitory  nerves.1  The 
medullary  center  of  the  vagus  may  be  stimulated  and  a  slow 
pulse  produced  reflexly  from  the  stomach,  as  in  dyspepsia, 
cancer,  or  ulcer,  from  the  intestines,  or  from  the  skin  or  sexual 
organs.  (Fig.  216.)  It  occurs  also  when  there  is  pressure 
within  the  cranium,  as  from  cerebral  abscess,  aneurysm, 
haemorrhage,  or  tumor;  in  meningitis,  either  simple  or  tuber- 

1  Wickham  Legg,  Bile,  Jaundice,  and  Bilious  Disorders,  London. 


1 88  THERAPEUTICS    OF    THE    CIRCULATION 

cular;  in  epilepsy,  general  paresis,  mania,  sunstroke,  melan- 
cholia, and  injuries  of  the  medulla  or  cervical  cord.  It  is  also 
brought  about  when  the  pressure  which  the  heart  has  to  over- 
come is  abnormally  high,  either  in  the  pulmonary  circulation, 
as  in  emphysema,  or  in  the  general  circulation,  as  in  chronic 
interstitial  nephritis.  The  variety  of  causation  is  so  great  that 
the  treatment  is  necessarily  very  different  in  many  of  those 
cases.  Speaking  generally,  however,  we  have  to  remove  the 
cause  as  far  as  it  is  in  our  power.  If  due  to  toxins,  we  must 
try  to  lessen  their  formation  in  the  stomach  and  intestines  by 
the  use  of  antiseptics  and  by  free  purgation,  more  especially  by 
the  use  of  mercurial  purgatives  and  salines,  so  as  to  clear  out 
the  bile,  in  which  toxins  are  largely  contained.  Where  the 
slow  pulse  is  due  to  reflex  inhibition  from  the  stomach,  we 
must  remove  the  source  of  irritation  and  lessen  the  reflex  ex- 
citability of  the  vagus  center.  We  may  do  this  by  the  use  of 
alkalies  and  bismuth  to  soothe  the  gastric  mucous  membrane, 
and  bromide  of  potassium  to  lessen  the  nervous  irritability.1 
In  all  cases  it  is  advisable  to  try  to  strengthen  the  heart  itself, 
and  nux  vomica  or  strychnine  with  iron  are  amongst  the  most 
useful  remedies  for  this  purpose. 

Irregularity  of  Pulse. — Alterations  in  the  rhythm  of  the 
heart,  alternating  tachycardia  and  brachycardia,  so  as  to  give 
an  irregularity  or  intermittence,  are  usually  due  to  a  combina- 
tion of  the  causes  that  produce  either  the  one  or  the  other. 
In  poisoning  by  digitalis,  for  example,  we  get  in  its  various 
stages  brachycardia,  irregularity,  and  tachycardia,  vide  p.  149. 
According  to  one  explanation,  this  occurs  as  the  inhibitory 
apparatus  is  stimulated,  or  has  begun  to  suffer  from  more  or 
less  complete  paralysis.  According  to  another,  it  depends  on 
the  rate  of  production  and  conduction  of  stimuli  in  the  heart 
itself.  The  treatment  of  irregularity  and  intermission  is,  there- 
fore, much  the  same  as  that  for  tachycardia  and  brachycardia. 
An  irregularity  of  the  pulse  may  sometimes  persist  for  years. 

1  Vide  author's  remarks  on  a  case  by  Dr.  Somerville,  Practitioner,  vol. 
xvi.,  p.  1 86. 


ANGINA    PECTORIS  189 

One  patient  of  mine,  who  is  now  seventy-nine  years  of  age,  had 
a  bigeminal  pulse,  that  is,  two  beats  in  rapid  succession  fol- 
lowed by  a  longer  pause,  for  many  years.  He  is  still  hale  and 
healthy.  A  relative  of  my  own  died  at  the  age  of  eighty-four, 
after  having  had  a  very  irregular  pulse  for  sixty-seven  years. 
This  irregularity  of  the  pulse  came  on  after  an  attack  of  rheu- 
matic fever  at  the  age  of  seventeen,  and  continued  all  the  rest 
of  her  life. 

Angina  Pectoris. — One  of  the  most  distressing  forms  of 
cardiac  disturbance  is  angina  pectoris.  I  have  already  men- 
tioned the  relationship  between  this  disease  and  diminished 
circulation  through  the  coronary  arteries,  as  well  as  the  prob- 
able causation  of  the  pain.  In  many  cases  this  is  situated  about 
mid-sternum,  but  it  is  frequently  felt  more  towards  the  cardiac 
apex,  and  often  radiates  towards  the  shoulders  and  down  the 
arms,  especially  the  left  arm.  As  I  have  already  said,  it  is 
probably  due  to  a  want  of  relationship  between  the  power  of 
the  cardiac  muscle  and  the  resistance  it  has  to  overcome.  It 
is  brought  on  by  anything  that  raises  the  blood  pressure 
quickly,  such  as  exertion  or  emotion,  and  especially  by  the 
emotion  of  anger,  which,  as  in  John  Hunter's  case,  may  bring 
about  a  fatal  attack  at  once.  Anything  that  interferes  with 
the  action  of  the  heart  tends  to  increase  the  pain,  and  thus 
distension  of  the  stomach  by  tilting  the  heart  up  makes  the 
patient  worse,  and  much  relief  is  afforded  by  the  administration 
of  carminatives,  which  bring  the  flatulence  away  and  allow  the 
heart  to  resume  its  normal  condition. 

During  the  process  of  digestion  the  blood  pressure  tends  to 
be  higher  than  usual,  and  immediately  after  digestion  pain  is 
brought  on  by  the  slightest  exertion  with  much  greater  ease 
than  during  the  fasting  condition. 

Treatment  of  an  Attack  of  Angina  Pectoris. — The  indica- 
tion for  treatment,  of  course,  is  to  relieve  the  heart  by  dilating 
the  vessels,  and  this  is  brought  about  most  quickly  by  the  use 
of  nitrite  of  amyl.1  Nitrobutyl  and  other  organic  nitrites  have 

aLauder  Brunton,  Lancet,  July  27,  1897,  and  Reports  of  the  Clinical  So- 
ciety, vol.  Hi.,  1870. 


FIG.  204. — Normal  pulse, 
right  radial. 


Fio.  205.— Normal  pulse, 
left  radial. 


FIG.  206 — Right  radial, 
during  angina. 


Fig.  207.— Left  radial. 


FIG.  208. — During  severe 
anginal  pain. 

FIG.  209.— Pain  nearly  but 
not  quite  gone,  a  little 
remaining  near  the  nipple 
after  giving  nitiite  of  amyl. 


FIG.  210.— Pain  quite  gone, 
but  afterwards  returned. 


FIG.  211. — Pain  quite  gone, 
which  did  not  return. 


FIG.  212. — Pain  coming  on 
at  1,  more  severe  at  2. 
Most  severe  at  Fig.  213. 


FIG.  213.— Pain  severe. 


FIG.  214.— Pain  relieved  by 
nitrite  of  amyl. 


FIGS.  204  to  214.     Tracings  of  the  pulse  in  angina  pectoris. 


DIET    AND    REGIMEN    IN    ANGINA  IQI 

a  similar  action,  but  nitrite  of  amyl  seems,  upon  the  whole,  to 
be  the  most  satisfactory.  Nitroglycerine  acts  nearly,  though 
not  quite  so  quickly,  and  is  more  convenient.  It  has  also  the 
advantage  of  dilating  the  vessels  for  a  longer  time  than  nitrite 
of  amyl.  It  may  be  given  in  solution  with  a  little  brandy  or 
ether,  or  the  patient  may  carry  about  with  him  nitroglycerine 
tablets,  each  containing  one-hundredth  of  a  grain,  made  up 
with  chocolate ;  and  the  best  plan,  as  a  rule,  is  not  to  swallow 
the  whole  tablet,  but  to  nibble  it  slowly  until  the  pain  has 
ceased.  If  half  a  tablet  is  sufficient,  it  is  not  necessary  to  take 
more;  but  if  one  is  insufficient,  then  as  many  more  may  be 
taken  as  are  necessary.  I  have  never  seen  any  bad  effect  from 
an  overdose  either  of  nitroglycerine  or  amyl  nitrite,  except 
headache,  giddiness,  or  transient  faintness.  When  the  attack 
is  excessively  severe  a  neuralgic  element  may  be  superadded  to 
the  physical  condition,  and  I  think  it  is  possible  that  sometimes 
it  may  come  on  independently.  At  any  rate,  a  subcutaneous 
injection  of  a  quarter  or  a  third  of  a  grain  of  morphine  may 
sometimes  be  necessary,  in  order  to  lessen  the  pain  and  give 
the  patient  relief,  and  a  few  whiffs  of  chloroform  will  deaden 
the  pain  until  the  morphine  has  had  time  to  take  effect. 

Diet  and  Regimen  in  Angina. — During  the  interval  the 
tension  should  be  kept  low  by  diet  as  nearly  as  possible  vege- 
tarian, taking  care  that  it  is  easily  digested  and  that  it  does 
not  give  rise  to  flatulence.  Tea  and  coffee,  and,  of  course, 
all  meat  extracts  which  contain  substances  of  the  purin  type 
and  tend  to  raise  the  blood  pressure,  should  be  avoided.  The 
bowels  should  be  kept  freely  open,  and  mercurials  should  be 
given,  once,  twice,  or  three  times  a  week  at  night,  followed 
by  a  saline  in  the  morning,  so  as  to  remove  from  the  body 
all  substances  likely  to  raise  the  blood  pressure.  Many  sub- 
stances having  a  poisonous  action  are  absorbed  by  the  liver 
and  excreted  in  the  bile.  They  are  reabsorbed  from  the  duo- 
denum, again  passed  to  the  liver,  and  again  excreted.  (Fig. 
215.)  This  may  go  on  for  a  long  time  in  the  entero-hepatic 
circulation,  until  they  either  accumulate  to  such  an  extent  that 


192 


THERAPEUTICS    OF    THE    CIRCULATION 


they  pass  into  the  general  circulation  and  act  upon  the  nervous 
system,  heart,  or  other  organs,  or  are  cleared  out  by  mercurial 
purgatives  and  salines.  Nitro-erythrol  in  doses  of  half  a  grain 
three  times  a  day,  or  more  if  required,  will  sometimes  keep  a 
patient,  who  would  otherwise  suffer  from  angina  pectoris,  per- 
fectly comfortable  for  years. 

All  such  persons,  however,  should  take  care  to  remain  quiet 
for  half  an  hour  at  least  after  every  meal,  and  when  they  get  up 
they  should  move  very  slowly  until  they  begin  to  get  warm. 
When  the  vessels  of  the  muscles  become  dilated,  patients  are 


Liver  with  bile- 

duct  leading  into 

the  duodenum. 

Portal  vein  with 
entero-hepatic  cir- 
culation, showing 

absorption  and  re- 
excretion  of  bile. 

Mesenteric  veins.   . 


Stomach. 


Small  intestines. 


Colon. 


FIG.   215.       Diagram  to   illustrate   the   entero-hepatic  circulation. 

frequently  able  to  walk  with  perfect  comfort  even  at  a  rapid 
pace.     Cf.  Effect  of  muscular  area,  p.  15. 

Cardiac  Asthma. — When  the  right  side  of  the  heart  is 
enfeebled  the  symptoms  of  cardiac  asthma  are  apt  to  come 
on.  The  patient  is  quite  comfortable  so  long  as  he  remains 
still,  but  the  least  exertion  brings  on  rapid  breathing,  or  even 
dyspnoea  and  distress.  This  condition  is  largely  due  to  de- 
generation of  the  right  side  of  the  heart,  consequent  upon 
interference  with  the  circulation  in  the  right  coronary  artery. 
It  may  be  associated  with  fatty  degeneration  of  both  sides  of 
the  heart,  but  it  may  also  occur  in  the  right  side  independently 


SLEEPLESSNESS  193 

of  the  left.1  Nitrite  of  amyl  is  not  of  so  much  use  in  this  as 
in  ordinary  angina,  as  the  pulmonary  circulation  does  not  seem 
to  be  affected  by  nitrites  to  the  same  extent  as  the  general 
circulation.  Inhalation  of  5  minims  of  iodide  of  ethyl  is 
sometimes  serviceable,  but  inhalation  of  oxygen  occasionally 
affords  very  great  relief,  and  in  a  case  which  I  recently  saw 
the  tension  in  the  radial  artery  rose  under  the  influence  of 
oxygen  to  an  extent  which  I  should  not  have  believed  if  I 
had  not  seen  it.  The  tension,  as  tested  by  Potain's  instrument, 
was  only  75  when  the  inhalation  was  begun,  and  in  the  course 
of  ten  minutes'  inhalation  it  rose  steadily  until  it  had  reached 
150. 

In  cardiac  asthma  gentle  exercises  are  useful  as  tending  to 
train  the  heart,  increase  its  nutrition,  and  thus  accelerate  the 
circulation  through  the  lungs.  At  the  same  time,  iodide  of 
potassium,  strychnine,  digitalis,  squill,  and  strophanthus  are  all 
useful,  as  well  as  Oertel's  treatment,  which  we  shall  presently 
have  to  consider  in  relation  to  valvular  disease. 

Sleeplessness. — Although  sleeplessness  may  occur  apart 
from  any  disease  of  the  heart,  yet  it  not  infrequently  occurs 
along  with  cardiac  disease,  and  forms  one  of  its  most  distress- 
ing symptoms.  In  many  cases  the  patient  is  intensely  drowsy, 
but  the  moment  he  falls  asleep  he  feels  a  sensation  of  intense 
distress,  and  awakes  with  a  start.  Sometimes  this  condition 
appears  to  be  aggravated  by  flatulent  distension  of  the 
stomach,  or  acidity,  and  it  may  be  somewhat  relieved  by  the 
use  of  bicarbonate  of  soda  and  carminatives,  alone  or  with 
rhubarb.  A  purely  milk  diet  for  some  days  may  also  be  use- 
ful. The  various  hypnotics  may  all  be  tried.  Paraldehyde 
is  sometimes  efficacious  in  drachm  doses,  trional  or  sulphonal 
in  20  or  30  grain  doses,  and  chloral  10-30  grain  doses,  with 
bromides  of  potassium,  sodium,  or  ammonium,  or  all  three 
mixed,  in  doses  of  30  to  60  grains.  As  chloral  has  a  some- 
what depressing  action  on  the  heart,  one  may  hesitate  to  give 
it  if  the  cardiac  action  is  very  weak,  but  this  very  action,  by 
lowering  the  blood  pressure,  increases  its  hypnotic  effect.  The 
Brunton,  Practitioner,  June,  1905. 


194 


THERAPEUTICS    OF    THE    CIRCULATION 


remedy  par  excellence  in  this  condition,  however,  is  opium  or 
morphine.  The  latter  may  be  given  either  by  the  mouth  or 
subcutaneous  injection,  and  the  former  either  by  the  mouth 
or  rectum.  A  convenient  way  is  to  draw  30-60  minims  of 
tincture  of  opium  into  a  glycerine  syringe  holding  2  drachms, 
then  draw  up  water  till  the  syringe  is  full,  and  inject  into  the 


NERVOUS  CENTRE 
,  or  VOMITIHC  /N 
|  THE  MEDULLA 


/NTEST1ME-    1-- 


UTERUS -\---J--V 


VESICAL 
NER  VES 


FIG.  216.      Diagram  showing  the  afferent  nerves  by  which  the  vomiting  center  may  be 

excited  to    action. 

rectum.  The  advantage  this  method  has  over  administration 
by  the  mouth  is  that  one  can  be  quite  sure  beforehand  that 
the  rectum  is  empty  and  that  absorption  will  take  place  quickly, 
whereas  the  stomach  may  contain  a  large  quantity  of  food  or 


AORTIC    DISEASE 


195 


fluid  with  which  the  opium  will  be  so  much  diluted  that  it  may 
have  hardly  any  effect.  Sometimes  neither  opium  nor  mor- 
phine seem  to  produce  the  desired  effect,  even  when  given  in 
full  doses,  and  in  such  cases  a  few  whiffs  of  chloroform  may 
be  given  so  as  just  to  allow  the  narcotic  to  take  effect.  And 
here  it  may  be  well  to  say  that  I  do  not  think  the  presence  of 
albumen  in  the  urine  contra-indicates  the  use  of  either  opium 
or  morphine.  The  susceptibility  of  patients  to  these  drugs 
varies  so  much  that  it  is  impossible  to 
fix  a  dose,  but  usually  one  may  begin 
with  ]/§  or  }4  of  a  grain  of  morphine 
subcutaneously,  and  increase  the  dose 
carefully  until  the  desired  result  has 
been  obtained.  Even  should  there 
seem  to  be  danger  in  pushing  the  nar- 
cotic, it  must  be  remembered  that  to 
withhold  it  also  entails  risk,  for  the 
exhaustion  of  the  patient  by  continued 
insomnia  cannot  but  tend  towards  a 
fatal  termination. 

Aortic  Disease. — As  I  mentioned 
before,    cases    of   aortic    stenosis 


or 


FIG.  217.  Diagram  to  illus- 
trate the  occurrence  of  syncope 
in  cases  of  aortic  regurgitation. 
In  a  the  normal  heart  with  full 

aortic  regurgitation  may  continue  for  carotid  and  free  supply  of  blood 

,  . .          r    ,•  '.i  •    •  •          to   the   brain   is   represented;    in 

a  length  of  time  without  giving  rise  b  the  carotid  is  shown  empty> 
to  any  symptoms  whatever,  and  are  ^  that  sync°Pe  ™™  occur  from 

.  blood     flowing     back     into     the 

reCOgmzed  Only  by  a  SyStollC  murmur  ventricle  as  well  as  onward  into 
rvupr  fh*»  sr>rta  in  t1i*»  racA  nf  thp  the  aorta:  in  c  is  shown  aortic 

over   me   aorta   m  tne  regurgitation  in  the  recumbent 

former,  and  a  diastolic  murmur  in  the  posture,  so  that  the  carotid  is 

..,         ,  __  x      i  •    i       T     weH  filled  and  regurgitation  into 

case  of  the  latter.     Here  I  think  I   the  heart  is  rather  less, 
ought  to  give  a  word  of  caution  as  to 

the  place  where  the  aortic  regurgitant  murmur  is  heard.  It 
is  usually  heard  quite  markedly  over  the  aortic  valves,  or  per- 
haps I  ought  to  say  rather  over  the  aortic  cartilage,  and  is 
propagated  down  the  sternum,  but  sometimes  is  not  heard  at 
all  at  the  base  of  the  heart,  and  is  only  audible  at  the  lower 
end  of  the  sternum  more  especially  to  its  left  side.  This  con- 


196  THERAPEUTICS    OF    THE    CIRCULATION 

dition  was  impressed  upon  me  by  the  fact  that  an  old  friend 
of  mine  in  Edinburgh  told  a  lady  that  she  had  aortic  regurgi- 
tation.  She  came  up  to  London  and  saw  the  late  Sir  Andrew 
Clark,  who  told  her  there  was  nothing  the  matter  with  her 
heart.  She  went  back  to  Edinburgh  and  rebuked  my  old 
friend  very  severely  for  having  frightened  her  unnecessarily. 
He  said  he  was  sorry,  but  nevertheless  she  had  aortic  regur- 
gitation,  and  if  she  would  go  back  and  ask  Sir  Andrew  to  ex- 
amine her  more  carefully,  he  would  find  it  too.  She  did  so, 
and  on  the  second  examination  Sir  Andrew  found  the  murmur 
as  my  friend  had  described  it,  and  wrote  to  him  acknowl- 
edging his  error.  Now,  no  one  could  possibly  doubt  the  great 
clinical  knowledge  and  exact  diagnosis  of  Sir  Andrew  Clark, 
and  the  reason  that  he  fell  into  error  was  simply  that  his 
waiting-room  was  filled  with  patients,  and  in  order  to  save 
time  he  did  not  ask  the  lady  to  loosen  her  stays.  On  listening 
over  the  part  of  the  chest  above  the  stays,  no  murmur  was 
audible,  and  it  was  only  after  the  stays  were  removed  that 
the  diastolic  murmur  at  the  lower  end  of  the  sternum  could  be 
distinguished. 

Persons  suffering  from  aortic  regurgitation  are  more  liable 
to  sudden  death  than  those  suffering  from  any  other  form  of 
cardiac  disease,  except  perhaps  those  who  have  angina  pec- 
toris ;  but  so  long  as  the  valvular  lesion  is  fully  compensated, 
all  that  is  necessary  is  to  warn  the  patient  against  sudden 
strain.  Many  of  them  might  walk  25  miles  in  a  day  without 
harm  or  even  with  positive  advantage,  but  20  yards  sudden 
spurt  to  catch  a  train  might  prove  fatal.  Although  sudden 
death  occurs  not  infrequently  in  aortic  regurgitation,  yet  per- 
haps a  still  more  frequent  course  of  the  disease  is  for  the  left 
ventricle  to  yield  before  the  strain,  and  then  the  mitral  valves 
become  incompetent,  so  that  we  get  all  the  consequences  which 
I  have  previously  described  from  backward  pressure  on  the 
lungs  and  right  heart.  In  uncomplicated  cases  of  aortic  regur- 
gitation, digitalis  is  likely  rather  to  add  to  the  danger  they 
already  incur  from  syncope  than  to  do  the  patients  good.  In 


MITRAL     REGURGITATION 


197 


A   O 


FIG.  218.  Diagram  of  the 
cardiac  dulness  before  and  after 
a  bath.  A  similar  effect  is  pro- 
duced by  gymnastic  exercises. 
The  thin  line  shows  the  gradu- 
ated dulness  before  and  the- 
thick  one  after.  A,  Nipple. 
B,  Nipple.  C,  Ensiform  cartil- 
age. (After  Schott.) 


some  cases,  however,  if  carefully  watched,  it  may  tend, 
especially  when  combined  with  strychnine  and  caffeine,  to  keep 
the  left  ventricle  from  yielding,  and  thus  maintain  the  patient's 
health. 

But  in  cases  where  the  ventricle  has  already  dilated  and 
the  mitral  valves  become  incompe- 
tent, we  have  to  treat  the  patient  just 
as  we  would  an  ordinary  case  of 
mitral  disease,  for  the  danger  then 
arises  from  impeded  pulmonary  cir- 
culation and  venous  stasis  rather 
than  from  imperfection  of  the  gen- 
eral circulation.  Such  cases,  how- 
ever, as  a  rule  require  to  be  treated 
rather  as  cases  of  advanced  mitral 
disease,  with  complete  rest,  than  as 
mild  cases  where  the  patient  may  be 
allowed  to  go  about. 

Mitral  Regurgitation. — Mitral  incompetence  is  much  more 
frequent  than  is  usually  thought,  for  people  go  about  with 
slight  mitral  leakage  and  present  no  symptoms,  so  that  the 
condition  of  the  valve  is  only  discovered  by  a  medical  exami- 
nation. These  patients  are  usually  told,  and  rightly  so,  not 
that  they  have  any  disease  of  their  valves,  but  that  their  heart 
is  a  little  weak,  and  they  must  be  careful  to  avoid  strain.  As 
a  general  rule,  this  is  all  that  is  necessary;  but  when  shortness 
of  breath  or  symptoms  of  venous  stasis  set  in,  more  active 
treatment  is  required,  and  here  digitalis  and  strophanthus  find 
their  proper  place. 

Nauheim  Treatment. — For  such  cases  also  the  treatment 
by  baths  and  exercises  is  useful.  The  system  of  applying 
them  has  been  well  worked  out  by  the  brothers  Augustus  and 
Theodore  Schott,  at  Nauheim,  and  the  treatment  is  often 
known  now  as  the  "  Nauheim  "  treatment.  At  Nauheim,  the 
water  as  it  issues  from  the  springs  is  very  highly  charged  with 
carbonic  acid,  but  this  is  allowed  to  escape,  and  the  water  to 


198 


THERAPEUTICS    OF    THE    CIRCULATION 


become  still,  for  the  baths  which  are  given  at  first,  and  it  is 
only  in  the  later  baths  that  the  effervescent  water  is  employed. 
Baths  are  usually  employed  every  other  day  during  a  course  of 


FIG.  219.  Pulse  tracing,  showing  the  effect  of  massage  and  graduated  movements. 
Each  tracing  is  taken  partly  with  a  slow  and  partly  with  a  quick  movement  of  the 
sphygmograph.  The  upper  shows  high  tension  and  a  feeble  heart;  the  lower  shows 
less  tension  and  a  stronger  heart.  These  tracings  I  owe  to  the  kindness  of  Dr. 
Gustav  Hamel,  to  whose  treatment  I  had  recommended  the  patient. 

four  to  six  weeks,  or  even  longer,  according  to  the  condition 
of  the  patient.  The  bath  at  first  lasts  only  about  six  minutes 
at  a  temperature  of  95.  The  duration  is  then  increased  to 
eight  or  ten  minutes,  and  the  temperature  is  lowered  to  92. 


F.  21-10-93.  before       exercise   31  oz. 


G  F    21-IO-B8-.  after    'exercise  3roz. 


FIG.   220.       Pulse  tracing  to   show  the  effect  of  exercises.       The  upper  tracing  shows 
the  pulse  before  and  the  lower  tracing  after  exercise. 

They  are  then  strengthened  further  with  the  mother  liquor 
obtained  by  evaporating  the  ordinary  water.  The  duration 
is  gradually  increased  to  fifteen  or  twenty  minutes  and  the 


EFFECTS  OF  NAUHEIM  TREATMENT 


199 


temperature  lowered  as  far  as  82.  Immediately  after  the  bath 
the  patient  must  rest  for  at  least  an  hour,  and  on  alternate 
days  movements  may  be  used.  I  give  here  a  list  of  the  move- 


G.F.   28-10-98.   before  I-  bath    3so7. 


FIG.  221.  Tracing  from  the  pulse  of  a  patient  aged  62,  with  gouty  kidney,  of  a 
failing  heart.  This  tracing  and  the  three  following  show  the  effect  of  Nauheim  baths 
in  increasing  the  cardiac  force  and  dilating  the  vessels. 


FIG.  222.      Effect  of  one  bath. 


tf>  bath  &  2  "—  effervescing  bath  3roi. 


FIG.  223.      From  the  same  patient. 


G.F.  10-12-98  after  19^    bath 


FIG.  224.      From  the  same  patient,  after  nineteen  baths. 

ments,  which   Professor   Schott  at  Nauheim  kindly  got  his 
attendant  to  show  me : 


2OO  THERAPEUTICS    OF   THE    CIRCULATION 

The  essential  part  of  these  movements  is  that  the  movement  shall  be 
slow  and  regular,  and  that  each  movement  shall  be  fully  carried  out.  The 
body  should  be  held  upright,  the  joints  should  be  kept  straight,  and  the 
resistance  applied  should  not  be  sufficiently  great  to  cause  any  tremor  of  the 
limbs  or  shortness  of  breath  in  the  patient.  The  resistance  may  either  be 
applied  by  the  patient  himself  putting  into  action  the  opposing  muscles  to 
those  which  affect  the  movement,  or  by  an  attendant  or  friend  gently 
opposing  the  movements. 

I.  The  arms  are  to  be  raised  slowly  outwards  from  the  side  until  they 
are  on  a  level  with  the  shoulder.    After  a  pause  they  should  be  slowly 
lowered. 

II.  The  body  should  be  inclined  sideways  as  much  as  possible  towards 
the  right,  then  to  the  left. 

III.  One  leg  should  be  extended  as  far  as  possible  sideways  from  the 
body,  the  patient  steadying  himself  by  holding  on  to  a  chair.     The  leg  is 
then  dropped  back.     The  same  movements  are  repeated  by  the  other  leg. 

IV.  The  arms  are  raised  in  front  of  the  body  to  a  level  with  the  shoulder, 
and  then  put  down. 

V.  The  hands  are  rested  on  the  hips,  and  the  body  is  bent  forwards  as 
far  as  possible,  and  then  raised  to  the  upright  position. 

VI.  One  leg  is  raised  with  the  knee  straight  forwards  as  far  as  possible, 
then  brought  back.     This  movement  is  repeated  with  the  other  leg. 

VII.  With  the  hands  on  the  hips,  the  body  is  twisted  round  as  far  as 
possible  to  the  right,  and  then  again  to  the  left. 

VIII.  With  the  hands  resting  on  a  chair  and  the  back  stiff  and  straight, 
each  leg  is  raised  as  far  as  possible  backwards,  first  one  and  then  the 
other. 

IX.  The  arms  are  extended  and  the  fists  supinated.    The  arms  are  then 
extended  outwards,  next  inwards  at  the  height  of  the  body. 

X.  Each  knee  is  first  raised  as  far  as  possible  to  the  body,  and  then  the 
leg  extended. 

XL  This  movement  is  the  same  as  IX.,  but  with  the  fists  pronated. 

XII.  Each  leg  is  bent  backwards  from  the  knee  and  then  straightened. 

XIII.  Each  arm  is  bent  and  straightened  from  the  elbow. 

XIV.  The  arms  are  brought  from  the  sides  forwards  and  upwards,  then 
downwards  and  back  as  far  as  they  will  go,  the  elbows  and  the  hands  being 
straight. 

XV.  The  arms  are  put  at  a  level  with  the  shoulder,  and  then  bent  from 
the  elbow  inwards  and  again  extended. 

XVI.  With  the  arms  in  front  at  the  level  of  the  shoulder  and  the  hands 
stretched,  the  arms  are  opened  out  sideways  and  then  brought  together. 

XVII.  The  arms  are  bent  from  the  elbow  outwards  and  extended. 

•.  •  There  should  be  a  pause  of  half  a  minute  between  each  successive  movement, 
such  as  raising  the  arms  and  lowering  them,  and  a  pause  of  one  or  two  minutes 
between  the  movements  of  different  kinds,  such  as  I.  and  II. 

After  the  course  is  over  it  is  advisable  for  the  patient  to  go 


OERTEL  S    TREATMENT  2OI 

some  place  for  an  after-cure,  where  he  can  follow  up  the  treat- 
ment by  graduated  exercise. 

Cartel's  Treatment. — This  treatment  by  graduated  exer- 
cise is  often  known  as  Oertel's.  The  principles  upon  which  it 
depends  are — (i)  that  the  cardiac  symptoms  are  due  to  dis- 
proportion between  the  force  of  the  heart  and  the  resistance 
it  has  to  overcome;  and  (2)  this  disproportion  is  to  be  rem- 
edied by  dietetics  and  by  exercise,  consisting  chiefly  of  gradu- 
ated walking  uphill. 

The  dietetic  rules  are — (i)  Give  such  food  as  will 
strengthen  the  cardiac  muscle;  and  (2)  diminish  the  amount 
of  liquid  consumed,  in  order  to  reduce  the  mass  of  circulating 
blood. 

The  exercises  are  intended  to  promote  elimination  of  liquid, 
especially  through  the  lungs  and  skin,  and  to  increase  the  nu- 
trition and  activity  of  the  heart.  In  aortic  regurgitation,  Dr. 
Schott  considers  that  the  work  of  the  heart  is  easier  when 
there  is  abundance  of  blood  to  make  up  for  the  loss  in  the 
general  circulation  sustained  by  regurgitation  during  the 
diastole.  He  therefore,  advises  a  very  full  diet;  but  in  mitral 
disease,  where  the  patient,  on  account  of  breathlessness,  can 
move  less  than  a  healthy  person,  he  advises  a  sparing  diet.  In 
chronic  myocarditis,  where  albumen  is  required,  but  not  nu- 
clein,  butcher's  meat  should  be  given  sparingly,  but  milk  and 
plasmon  freely.  In  aortic  disease  he  allows  two  pints  of  fluid 
a  day,  and  as  much  as  three  pints  if  the  weather  be  hot;  but 
if  there  is  any  interference  with  the  pulmonary  circulation, 
as  shown  by  shortness  of  breath,  he  only  allows  between  a 
pint  and  a  half  and  two  pints.  In  mitral  disease  he  only 
allows  about  a  pint  and  a  quarter  to  a  pint  and  a  half. 

The  exercise  consists  in  gentle  walking  up  graduated  slopes. 
The  first  walk  is  taken  upon  a  very  gentle  slope,  and  only  for 
a  short  distance.  This  is  increased  daily,  and  when  the  patient 
can  walk  on  the  level  or  gentle  slope  without  shortness  of 
breath  he  walks  up  a  somewhat  steeper  grade.  The  steepness 
is  gradually  increased  as  the  patient's  heart  will  bear  it.  Such 


2O2  THERAPEUTICS    OF    THE    CIRCULATION 

walks  have  been  well  arranged  at  Llangammarch  in  this 
country,  and  one  of  the  best  places  abroad  is,  I  think,  Baden- 
weiler,  although  there  are  numerous  other  places  where  similar 
walks  have  been  laid  out. 

Treatment  of  Venous  Stasis. — In  cases  of  well-marked 
venous  stasis,  whether  it  be  dependent  upon  mitral  stenosis  or 
regurgitation,  or  dilatation  of  the  right  side  of  the  heart,  con- 
sequent upon  bronchitis  and  emphysema,  the  best  results  are 
certainly  afforded  by  complete  rest,  in  bed  if  possible,  or  in  a 
chair  if  the  dyspnoea  be  so  great  that  the  patient  cannot  stay 
in  bed.  In  such  cases  massage  comes  in  most  usefully,  the 
hand  of  the  masseur  or  masseuse  supplying,  as  it  were,  the 
place  of  an  auxiliary  heart  in  helping  the  venous  return,  and 
the  place  of  the  lymph  hearts  which  we  find  in  batrachians 
(cf.  p.  9). 

Graduated  Exercises. — Gentle  movements  are  also  useful ; 
for  example,  the  patient  may  bend  one  finger  gently  against 
resistance  the  first  day  or  even  the  first  forenoon.  In  the  after- 
noon he  may  straighten  the  same  finger  against  resistance. 
Next  day  he  may  bend  two  fingers,  and  in  the  afternoon 
extend  two  fingers  and  so  on,  gradually  including  the  wrist, 
the  fore-arm,  and  even  the  arm.  The  resistance  should  at 
first  be  very  slight  indeed,  and  may  be  gradually  increased  as 
the  patient  can  bear  it.  Such  gentle  movement  as  simply 
flexing  a  finger  might  seem  at  first  sight  to  be  useless,  but 
if  any  of  you  will  put  your  hand  upon  your  biceps  and  get 
someone  elese  to  hold  your  finger  while  you  flex  against  resist- 
ance, you  will  soon  discover  that  it  is  not  merely  the  muscles 
of  the  finger  alone  that  are  in  action,  but  that  the  biceps,  and 
even  the  muscles  of  the  trunk  take  part  in  the  movement.  The 
effect  of  massage  and  exercise  on  the  pulse  is  shown  by  the 
tracing  in  Fig.  219,  where  the  high  tension  with  slight  move- 
ment of  the  radial  artery  is  converted  into  less  tension,  quicker 
contraction  of  the  heart,  and  more  active  movement  of  the 
vessel  increasing  the  self -massage  both  of  the  arteries  and  the 
heart. 


ELIMINATION  2O3 

Inhalation  of  oxygen  certainly  gives  great  help  in  some 
cases,  and  I  think  it  is  possible  that  occasionally  the  deep 
inhalations  which  patients  take  when  they  are  inhaling  the 
oxygen  may  help  mechanically  by  producing  self -massage  of 
the  heart. 

Elimination. — I  have  already  spoken  of  the  action  and  use 
of  digitalis  and  its  congeners  as  well  as  of  caffeine  in  such 
cases,  and  have  given  you  the  indications  for  employing  them, 
and  also  referred  to  the  symptoms  which  necessitate  their  dis- 
continuance. But  here,  again,  you  must  remember  that  the 
imperfect  circulation  and  imperfect  respiration  tend  to  pro- 
duce the  products  of  waste,  and  we  must  look  to  the  elimina- 
tion of  these  by  means  of  purgatives  such  as  calomel  and 
compound  jalap  powder.  Half  a  drachm  to  a  drachm  of  com- 
pound jalap  powder  every  morning,  or  every  other  morning, 
is  a  most  useful  agent  in  withdrawing  water  from  the  body, 
and  thus  aiding  the  action  of  the  kidneys,  especially  when 
ascites  is  present.  Its  efficacy  is,  I  think,  increased  by  the 
addition  of  a  drachm  of  potassium  bitartrate  to  every  dose. 
Another  well-tried  remedy  is  the  Haustus  Scoparii  Composi- 
tus  of  St.  Bartholomew's  Hospital.  Its  composition  is  as 
follows : 

Spirit  of  Juniper 30  minims 

Potassium  Tartrate 20  grains 

Decoction  of  Broom  Tops to  I  ounce 

The  action  of  mercurials  is  not  properly  understood,  but  it  is 
very  curious  to  note  how  frequently  the  addition  of  a  little 
mercury  to  digitalis  increases  its  beneficial  action.  The  old- 
fashioned  pill  of  one  grain  of  powdered  digitalis,  one  of 
powdered  squill,  and  one  of  blue  pill,  frequently  succeeds  when 
other  remedies  fail.  At  St.  Bartholomew's  we  have  two  grains 
of  extract  of  hyoscyamus  added  to  this  pill,  in  order  to  lessen 
any  irritation  of  the  stomach  or  bowels  that  the  other  ingre- 
dients might  produce:  whilst  in  other  hospitals  the  quantity 
of  squill  and  blue  pill  is  increased  to  two  grains  and  the 
amount  of  digitalis  is  kept  at  one  grain. 


2O4  THERAPEUTICS    OF    THE    CIRCULATION 

Milk  Diet  and  Chloride-free  Food. — Lately  a  great  deal 
of  attention  has  been  given,  especially  in  France,  to  the  effect 
of  chlorides  upon  transudation  from  the  vessels  into  the  tis- 
sues. Chlorides  appear  to  favor  this,  and  therefore,  although 
they  may  be  useful  in  health,  they  are  disadvantageous  in 
dropsy,  and  accordingly  a  diet  containing  a  small  quantity  of 
chlorides  is  used.  Calcium  and  its  salts  appear  to  have  a  con- 
trary action,  and  rather  to  diminish  transudation.  The 
amount  of  chlorides  in  milk  is  not  great,  the  quantity  of  cal- 
cium is  considerable,  and  the  lactose  appears  to  have  a  diuretic 
action;  so  that  frequently  we  notice  patients  suffering  from 
mitral  disease  when  put  to  bed  with  entire  rest,  with  massage, 
with  an  entirely  milk  diet,  just  as  if  they  were  typhoid  patients, 
and  with  the  digitalis  and  blue  pill  already  mentioned,  fre- 
quently improve  with  great  rapidity.  But  a  milk  diet  does 
not  always  suit ;  and  consequently,  in  France,  bread  made  with 
sugar  instead  of  salt,  farinaceous  preparations  also  made  with 
sugar  and  without  salt,  and  boiled  meat  without  salt,  but  with 
sweetened  tomato  sauce  or  some  such  condiment  to  make  it 
pleasant,  and  eggs,  either  boiled  without  salt  or  in  the  form 
of  a  sweet  omelette,  and  plasmon,  may  all  be  used.  I  have 
only  tried  this  in  a  few  cases,  but  certainly  the  treatment  has 
appeared  satisfactory. 

Tapping. — When  the  oedema  becomes  very  great  in  the 
legs  or  scrotum,  it  is  advisable  to  let  it  out,  and  the  way  in 
which  this  can  be  done  depends  to  a  great  extent  upon  the 
character  of  the  patient.  In  some,  Southey's  or  Bartel's  tubes 
may  be  used  to  drain  the  legs  or  scrotum,  but  when  the  patient 
is  restless  these  are  apt  to  be  dragged  from  their  place,  and 
almost  the  only  way  is  to  puncture  the  legs  either  with  an 
ordinary  sewing  needle  or  with  a  triangular  surgical  needle,  or 
make  small  incisions  with  the  lancet  or  bistoury,  and  surround 
the  parts  with  absorbent  cotton  wool,  which  can  be  frequently 
changed,  and  place  a  waterproof  sheet  under  the  part  to 
prevent  the  bed  from  becoming  soaked.  Effusion  into  the 
serous  cavity  of  the  abdomen  or  pleura  must  be  removed  by 
tapping,  if  it  reach  any  great  extent. 


SENILE   RISE    OF    PRESSURE  2O$ 

Surgical  Treatment  of  Cardiac  Diseases. — In  some  cases 
of  cardiac  disease  treatment  may  for  a  time  be  beneficial  and 
relieve  the  patient's  sufferings,  but  may  be  quite  impotent  to 
effect  a  cure  or  to  render  the  patient  fit  for  any  exertion 
whatever.  This  is  especially  marked  in  mitral  stenosis,  and 
I  believe  that  in  some  cases  of  this  form  of  cardiac  disease 
surgical  treatment  may  yet  effect  a  cure.1 

Senile  Rise  of  Pressure. — I  must  not  finish  my  Lectures 
without  drawing  attention  to  one  condition  which  is  very 
common,  and  which  may  become  still  commoner  as  increasing 
medical  knowledge  regarding  the  prevention  of  infective  dis- 
ease leads  to  prolongation  of  life.  In  all  men  with  advancing 
years  the  arteries  tend  to  lose  their  elasticity  and  become  more 
rigid.  The  time  at  which  this  alteration  takes  place  varies  in 
different  individuals  and  in  different  families,  and  the  saying 
is  a  particularly  true  one  that  "  a  man  is  as  old  as  his  ar- 
teries " ;  so  that  not  infrequently  we  find  strong  athletic  and 
robust  families  who  are  not  only  powerful  both  physically  and 
mentally,  but  apparently  free  from  disease,  and  who  are  yet 
short-lived.  I  believe  that  these  lives  might  frequently  be 
lengthened  by  timely  attention  to  the  condition  of  the  arteries, 
more  especially  by  measurement  of  the  blood  pressure,  and 
adjustment  of  work,  of  exercise,  and  of  food  to  the  condition 
that  is  found.  The  combination  of  atheromatous  arteries  and 
high  blood  pressure  is  very  common,  and  the  risks  it  entails 
are  twofold  :  ( i )  It  may  lead  to  cardiac  failure,  the  heart  being 
unable  to  overcome  the  excessive  tension,  and  this  is  all  the 
more  common  when  it  is  affected  by  fatty  or  fibroid  degenera- 
tion; (2)  a  vessel  may  rupture  in  the  brain,  and  give  rise  to 
sudden  death,  to  hemiplegia,  or,  if  the  haemorrhage  be  small, 
to  local  paralysis,  sensory  affections,  or  mental  deterioration, 
the  result  depending  on  the  part  of  the  brain  affected.  Simi- 
lar results  may  ensue  from  blocking  of  the  arteries  by  ather- 
oma.  These  conditions  are  illustrated  by  Figs.  225  and  226. 

1  Lander  Brunton,  "On  the  Possibility  of  Treating  Mitral  Stenosis  by 
Surgical  Methods,"  Lancet,  8th  February,  1902. 


2O6 


THERAPEUTICS    OF    THE    CIRCULATION 


Senile  Decay. — In  the  decade  for  1891  to  1900  of  persons 
above  the  age  of  seventy-five  years,  no  less  than  34,822  died 
from  heart  disease,  and  39,662  from  diseases  of  the  blood- 


FIG.  225.      Distribution  of  the  arteries  in  the  brain.       (After  Ross.) 

vessels  above  that  age.  Nor  does  this  even  cover  all  the  mis- 
chief done  by  diseases  of  the  blood-vessels,  for  apoplexia, 
paralysis,  and  senile  decay  may  all  be  reckoned  as  secondary 


FIG.  226.      Cerebral  cortex  showing  the  distribution  of  function.       (After  Osier.) 

to  disease  of  the  cerebral  vessels.  In  his  most  instructive  book, 
On  the  Nature  of  Man,  Metchnikoff  mentions  that  there  are 
two  classes  of  phagocytes  in  the  body,  the  small  or  microphags, 


SENILE    DECAY 


207 


and  the  large  or  macrophags.  The  function  of  the  microphags 
is  to  rid  us  of  microbes,  that  of  the  macrophags  is  to  heal 
mechanical  injuries,  such  as  haemorrhages,  wounds,  and  so 
forth.  In  the  brains  of  old  persons  and  animals  a  number  of 
nerve  cells  are  surrounded  and  devoured  by  macrophags  (Fig. 
227),  and  Metchnikoff  thinks  himself  justified  in  asserting 
that  senile  decay  is  mainly  due  to  the  destruction  of  the  higher 
elements  of  the  organism  by  macrophags.  Other  parts  of  the 
body  also  are  not  safe  from  their  attacks,  and  the  kidneys  may 
likewise  suffer  (Fig.  228).  But  the  function  of  the  macro- 
phags is  not  to  attack  healthy  tissues ;  it  is  to  remove  those  the 
vitality  of  which  is  destroyed  or  impaired,  and  so  long  as  the 


FIG.  227.  Cell  from  the 
brain  of  a  woman,  aged  100 
years,  being  devoured  by 
macrophags.  (From  Metchni- 
koff.) 


FIG.  228.  Section  of  a  renal  tubule  in- 
vaded by  macrophags,  from  the  body  of 
an  old  man,  aged  90  years  (m  =  macro- 
phags).  (From  Metchnikoff.) 


brain  cells  are  abundantly  supplied  with  blood  they  will  prob- 
ably be  allowed  to  remain  uninjured  by  the  attacks  of  the 
macrophags.  I  think,  therefore,  that  while  senile  decay  may 
be  actually  produced  by  the  macrophags,  we  are  justified  in 
believing  that  it  really  originates  in  an  alteration  of  the  blood- 
vessels. 

Treatment  of  Senile  Conditions  of  the  Vessels. — Al- 
though I  do  not  quite  agree  with  him  in  every  respect,  I  think 
that  my  former  pupil  and  old  friend,  Dr.  Haig,  has  done  a 
very  great  service  by  drawing  general  attention  to  the  injurious 
effects  of  a  too  highly  nitrogenous  diet.  In  cases  where  the 


2O8  THERAPEUTICS    OF    THE    CIRCULATION 

arterial  tension  tends  to  rise  much  above  the  normal,  the  pro- 
teids  in  food  should  be  kept  as  low  as  they  possibly  can,  con- 
sistently with  the  proper  performance  with  the  bodily  func- 
tions. The  bowels  should  also  be  kept  free  either  by  the  use 
of  salines  or  by  small  quantities  of  some  aperient  such  as  cas- 
cara,  aloes,  or  rhubarb,  along  with  each  meal,  so  that  the 
natural  stimulating  effect  of  food  upon  the  bowels  as  well  as 
the  stomach  should  be  increased.  Nor  should  the  occasional 
use  of  a  mercurial  purgative  be  omitted,  and  here  I  may  men- 
tion that  the  danger  of  mercury  in  albuminuria  has,  I  think, 
been  greatly  exaggerated,  and  has  sometimes  in  my  own  ex- 
perience been  productive  of  much  harm,  for  I  have  met  practi- 
tioners who  have  been  so  imbued  with  the  fear  of  mercury 
that  they  would  not  give  it  in  cases  of  cardiac  disease  either 
as  a  purgative  or  in  combination  with  digitalis,  because  albu- 
men had  appeared  in  the  urine.  Whereas  in  these  very  cases 
mercury  was  one  of  the  best  things  to  restore  the  circulation 
to  its  normal  condition  and  cause  the  albumen  to  disappear. 

The  steady  employment  of  iodides  is  sometimes  most  use- 
ful, and  I  have  found  great  advantage  in  a  number  of  cases 
of  high  tension  from  20  grains  of  nitrate  of  potash  along  with 
YI  to  2  grains  of  nitrite  of  sodium  given  in  a  tumbler  of  water 
or  aperient  water  every  morning  on  rising.  This  seems  to 
keep  the  tension  from  rising  too  high,  and  the  treatment  may 
be  continued  with  advantage  for  years. 

Where  this  is  insufficient,  it  may  be  supplemented  by  two 
or  three  grains  of  sodium  nitrite  in  water  every  four  hours,  or 
by  nitro-erythrol  in  doses  of  y*  to  2  grains,  or  Koo  grain  nitro- 
glycerine in  tablets  or  solution.  Ammonium  hippurate.  as 
recommended  by  Oliver,  may  also  be  useful. 

In  very  high  tension  it  may  be  advisable  to  bleed  from  the 
arm.  The  effect  of  this  in  relieving  angina  was  most  strik- 
ingly shown  in  the  patient  whom  I  was  afterwards  able  to 
relieve  by  the  use  of  nitrite  of  amyl  (Clin.  Soc.  Rep.,  vol.  Hi., 
1870;  and,  Collected  Papers,  p.  186). 

By  careful  estimation  of  the  blood  pressure,  and  by  keep- 


SENILE    CONDITIONS    OF    THE    VESSELS  2CK) 

ing  the  tension  at  a  proper  level  by  diet  regimen  and  medi- 
cines, I  believe  that  the  cardiac  failure  or  the  cerebral  apoplexy, 
which  are  common  causes  of  death  in  advanced  years,  may  be 
averted  for  years,  and  the  life  not  only  prolonged  greatly,  but 
the  senile  decay  or  paralysis,  which  are  so  trying  to  the  patients 
themselves  and  their  friends,  may  be  prevented. 

As  I  mentioned  in  my  first  Lecture,  the  therapeutics  of  the 
circulation  is  a  very  large  subject,  and  I  have  been  able  to 
treat  it  only  sketchily  and  imperfectly,  but  the  general  outlines 
I  have  given  may  be  a  guide  in  further  reading  on  the  subject; 
whilst  the  prominence  I  have  given  to  the  subjects  at  which  I 
have  worked  experimentally  is,  I  believe,  in  accordance  with 
the  general  purpose  of  the  University  in  establishing  such 
lectures. 


APPENDIX  A 

Functions  of  Protoplasm. — In  Lecture  (I.,  page  24),  I 
mentioned  that  protoplasm  can  contract  independently  of 
nerves,  and  that  partially  differentiated  protoplasm  might  pos- 
sess the  functions  both  of  muscle  and  nerve.  It  was  impos- 
sible to  enter  more  fully  into  this  subject  in  the  lectures;  but 
as  it  is  one  of  great  interest,  I  have  thought  it  worth  while  to 
deal  with  it  in  an  appendix,  especially  as  books  in  which  it  is 
discussed  are  not  always  of  ready  access,  even  to  those  who 
are  able  to  consult  public  libraries. 

Contractility  and  Conduction  of  Stimuli  by  Vegetable 
Protoplasm. — My  attention  was  first  directed  to  this  subject  by 
the  late  Professor  J.  Hutton  Balfour,  and  in  his  class  of  Botany 
in  1865  I  wrote  a  prize  essay  on  the  movements  of  plants  and 
the  action  of  drugs  upon  them.  The  experiments  I  made  on  the 
subject  added  little  to  the  results  already  obtained  by  Marcet, 
Macaire-Prinsep,  Dutrochet,  Brucke,  Livingston,  and  Cold- 
stream,  and  the  essay  was  not  published.  I  experimented 
chiefly  with  the  sensitive  plant  (Mimosa  pudica).  The  leaves 
of  this  plant  have  numerous  small  leaflets  standing  out  on  each 
side  of  the  midrib,  or  like  the  teeth  of  a  double  comb.  If  the 
swelling  at  the  base  of  one  be  touched,  the  leaflets  fold  up 
together,  and  the  irritation  spreads  to  the  neighboring  leaf- 
lets, which  fold  up.  If  the  plant  is  in  good  condition,  the 
stimulus  affects  the  whole  leaf,  which  falls  down  instead  of 
standing  out  from  the  stem.  Marcet  found  that  chloroform 
at  first  acts  as  an  irritant,  and  causes  the  leaflets  to  fall.  After 
a  while  they  recover,  but  are  then  insensible  to  touching.  This 
condition  appears  to  be  analogous  to  the  effect  of  chloroform 
on  animals,  in  which  it  frequently  produces  struggling  and 
afterwards  anaesthesia.  I  found  in  my  experiments  that 
alcohol  dropped  on  the  leaves  had  a  somewhat  similar,  though 
less  marked  effect.  Perhaps  one  passage  from  my  unpub- 
lished essay  may  not  be  without  interest,  and  so  I  give  it  here ; 
"  When  I  began  to  write  this  essay,  I  had  an  inclination  to 
the  belief  that  plants  as  well  as  animals  have  a  nervous  sys- 
tem, but  I  now  think  that  if  they  do  possess  something  anal- 
ogous to  it,  yet  it  is  very  different  in  kind.  However,  it  is 


212  THERAPEUTICS    OF    THE    CIRCULATION 

possible  that  researches  on  the  motions  in  cells  of  plants  may 
yet  lead  to  some  light  on  that  mysterious  part  of  the  animal 
economy,  and  help  to  solve  the  question  which  so  long  has 
engaged  the  attention  of  all  medical  men,  '  How  do  medicines 
act?' — for  most  of  those  are  poisons,  and  if  we  could  only 
find  out  how  poisons  act  on  the  vegetable  organism,  a  great 
step  would  be  gained  towards  our  knowledge  of  their  action 
on  animals." 

Animal  Protoplasm. — In  the  amoeba  (Fig.  27,  page  26), 
and  in  the  leucocytes  of  higher  animals,  every  part  of  the 
protoplasm  of  which  they  consist  appears  capable  of  exer- 
cising the  functions  of  receiving  and  conducting  stimuli,  of 
contracting,  and  of  secreting.  In  low  organisms,  such  as 


FIG.  229.  Neuro-muscular  cells  from  the  fresh-water  hydra,  a,  A  neuro-muscular 
cell  seen  in  profile;  b,  a  three-quarter  view;  c,  a  frontal  view.  (After  Ranvier, 
Lefons  d'Anatomie  G&n&rale  sur  le  Syst&me  Musculaire,  Paris,  Delahaye  &  Co.,  1880, 
p.  328.) 

the  hydra,  differentiation  occurs  but  incompletely,  and  the 
same  is  the  case  in  the  embryos  of  higher  animals. 

Neuro-muscular  Cells. — It  has  been  shown  by  Kleinenberg 
and  Ranvier  that  in  the  fresh-water  hydra  the  protoplasm  in 
some  of  the  cells  appears  to  have  the  power  of  receiving 
stimuli  and  also  of  contracting;  in  fact,  of  performing  the 
functions  of  both  nerve  and  muscle.  To  these  cells  the  name 
of  neuro-muscular  has  been  given.  Ranvier's  description  is  so 
clear  that  I  have  translated  it  almost  verbatim.1 

The  body  of  the  hydra  consists  of  a  cylindrical  tube,  open  at 
one  end.  The  body-wall  consists  of  three  layers :  an  inner  or 
endoderm,  a  middle  or  mesoderm,  and  an  outer  or  ectoderm. 

1  Ranvier,  Legons  d'Anatomie  Generate  sur  le  Systcme  Musculaire,  Paris 
(A.  Delahaye  &  Co.),  1880,  pp.  325  et  seq. 


APPENDIX  A 


213 


The  ectoderm  is  composed  of  large  cells  lying  adjacent  to 
one  another,  and  forming  a  protecting  layer.  Under  this  is 
the  mesoderm  of  interlacing  fibers.  Internal  to  this  is  the 
endoderm,  consisting  of  large  cells  arranged  like  epithelium. 

The  ectoderm  sends  into  the  mesoderm  a  series  of  proc- 
esses. Each  of  these  proceeds  from  the  body  of  an  ecto- 
dermal  cell  of  which  it  seems  to  form  a  part.  Kleinenberg, 
who  first  described  them,  supposes  that  the  ectodermic  cell 
with  its  mesodermic  prolongation  constitutes  a  neuro-muscular 
element  (Fig.  229).  The  ectodermic  cell  corresponds  to  an 
ordinary  nerve-cell,  and  is  receptive,  sensory,  and  excito- 
motory.  The  mesodermic  prolongation  represents  a  muscular, 
or  at  all  events,  a  contractile  element. 

In  the  hydra,  then,  he  supposes  that  the  function  of  sensa- 
tion is  connected  with  stimulation  of  the  ectodermic  portion  of 
the  cell,  and  motion  with  its  meso- 
dermic or  muscular  portion.  The 
three  layers  in  the  body  of  the  hydra 
correspond  to  the  three  layers  of  the 
blastoderm  in  a  vertebrate  embryo. 
The  ectoderm  is  analogous  to  the 
outer  layer  of  the  blastoderm,  from 
which  not  only  the  integument  which 
covers  the  exterior  of  the  animal  is 
developed,  but  also  the  central  ner- 
vous system,  which  originates  from 
that  part  of  the  layer  which  is  sepa- 
rated by  the  involution  of  the  primi- 
tive groove.  The  mesoderm  of  the 
hydra  corresponds  to  the  muscular 
system  of  vertebrates,  which  is  de- 
veloped in  the  middle  layer  of  the 
blastoderm,  and  remains  connected 
on  the  one  hand  with  the  nerve  cen- 
ters which  have  been  separated  from 
the  external  layer  by  involution,  and 
on  the  other  with  that  part  which 
develops  into  integument. 

In  the  hydra  the  ectodermic  cells  have  three  functions,  viz., 
(i)  they  protect  the  surface;  (2)  they  act  as  sensory  nerves; 
and  (3)  as  excito-motor  agents. 


FIG.  230.  Primitive  bundle 
from  a  mammalian  embryo 
(about  the  third  month),  ex- 
amined in  strongly  iodized 
serum.  n,  Nuclei  surrounded 
by  glycogenic  substance  g;  s, 
striated  cortex;  p,  central  cyl- 
inder of  protoplasm.  (After 
Ranvier,  Le(ons  d'Anatomie 
Generate  sur  le  Musculaire, 
Paris,  Delahaye  &  Co.,  1880,  p. 
374-) 


214 


THERAPEUTICS    OF    THE    CIRCULATION 


Amongst  animals  more  completely  differentiated,  these 
different  qualities,  instead  of  being  united  in  a  single  ana- 
tomical element,  become  associated  with  special  elements 
whose  forms  are  adapted  to  their  functions. ' 

The  hydra  when  irritated  contracts  strongly.  According  to 
Ranvier,  it  is  very  easy  to  understand  this,  if  its  mesodermic 
cells  are  contractile.  But  it  can  elongate  itself  as  well  as 
contract,  and  this  active  elongation  Ranvier  says  is  difficult  to 


FIG.  231. 


Cells  of  involuntary  muscle  from  the  bladder  of  the  dog,   showing  traces 
of  striation.       (After   Schwalbe.) 


understand,  and  he  will  not  offer  an  explanation  of  it.  But  if 
we  suppose  the  cells  to  have  the  power  of  contracting  trans- 
versely as  well  as  longitudinally,  vide  page  45,  the  explanation 
is  simple  enough.  In  embryonic  muscle  the  fibers  are  only 


FIG.  232.  Purkinje's  fibers  from  a  sheep's  heart,  n,  Nuclei;  c,  protoplasm;  f, 
striated  muscular  substance.  (After  Ranvier,  Legons  d'Anatomie  G6n6rale  sur  le 
Systtme  Musculaire,  Paris,  Delahaye  &  Co.,  1880,  p.  300.) 

striated  at  the  side,  and  the  anterior  consists  of  undifferentiated 
protoplasm  (Fig.  230). 

A  slight  tendency  to  striation  has  been  observed  by  Schwalbe 
in  the  involuntary  muscle  of  the  bladder  in  the  dog  (Fig.  231). 


APPENDIX   A 


215 


In  the  cells  of  Purkinje  a  striation  similar  to  that  in  embry- 
onic muscle  (Fig.  230)  exists  at  the  periphery  of  the  cell 
(Fig.  232).  _ 

The  function  of  these  cells  has  long  been  a  mystery,  but 
they  are  now  coming  to  be  regarded  as  the  conductions  of 
stimuli  from  the  auricles  to  the  ventricles,  and  thus  maintain- 


Riffht  aortic  semilunar  valve 


ATRIO-VENTRICULAR 
BUNDLE 


FIG.   233.      Atrio-ventricular   bundle   of   Stanley-Kent   and   His,    seen   from   the  right 
ventricle.      (From  Morris's  Anatomy,  after  Retzer.)     For  description,  vide,  p.  37. 

ing  or  assisting  to  maintain,  in  conjunction  with  nerves,  the 
coordination  of  the  auricular  and  ventricular  pulsations 
(page  36). 

Bundle  of  Stanley-Kent  and  His. — This  has  been  de- 
scribed in  the  lectures  (page  37),  but  its  position  and  rela- 
tions will  be  more  easily  understood  from  the  accompanying 
figure  (Fig.  233). 


APPENDIX  B 

Instruments  for  Measuring  the  Blood-pressure  in  Man. 
— Janeway's  has  been  mentioned  (page  81),  but  may  be  here 
described. 

It  employs  the  method  of  circular  compression,  introduced 
by  Riva-Rocci  and  Hill,  with  the  wide  armlet,  proved  essen- 
tial by  v.  Recklinghausen.  The  jointing  of  the  manometer 
tube  is  copied  from  Cook,  the  use  of  a  Politzer  inflater  from 
Erlanger.  The  apparatus  is  designed  to  embody  in  a  portable 
clinical  sphygmomanometer,  which  shall  measure  both  systolic 


FIG.  234.      Janeway's  sphygmomanometer. 

and  diastolic  pressures,  every  requirement  for  accuracy  and 
substantiality. 

The  sphygmomanometer  consists  of  three  essential  parts. — 
A,  Manometer,  of  U-tube  form,  with  upper  part  jointed,  fixed 
to  the  under  side  of  case  lid.  The  scale  is  graduated  empiri- 
cally for  each  manometer,  and  is  accurate.  B,  Compressing 
armlets,  consisting  of  a  hollow  rubber  bag  12  by  18  cm. 
This  is  attached  to  an  outer  leather  cuff,  which  fastens  by  two 
encircling  straps  with  friction  buckles.  C,  Inflator,  an  8-oz. 

216 


APPENDIX    B 


217 


Politzer  bag  with  valve.  D,  Tube  connecting  the  manometer 
and  armlet.  E,  stopcock  with  needle  valve  to  allow  slow  re- 
lease of  pressure.  F,  A  small  cock  to  close  the  open  end  of 
the  manometer.  G,  A  rubber  joint  which  is  compressed  by  a 
block  and  closes  the  other  end  of  the  manometer  when  the  box 
is  shut.  H,  is  a  spring  to  hold  the  stopcock  in  place  when  the 
box  is  shut.  It  is  made  by  C.  E.  Dressier  &  Co.,  143-147 
East  Twenty-third  Street,  New  York.  It  can  be  obtained 
from  Mr.  Hawksley,  357  Oxford  Street,  London. 

C.  J.  Martin's  new  modification  of  Riva-Rocci's  instru- 


FIG.  235.      C.   J.   Martin's  modification   of  Riva-Rocci's  sphygmomanometer. 

ment  is  one  of  the  best  of  the  new  instruments  which  have 
been  introduced  since  these  lectures  were  delivered.  His 
earlier  one  is  described  at  page  78.  The  newer  one  has  all 
the  advantages  of  the  earlier,  and  has  the  additional  one  of 
being  portable.  Mercurial  manometers,  as  a  rule,  are  trouble- 
some, as  the  mercurial  column  is  apt  to  break  or  the  mercury 
to  be  spilled.  The  india-rubber  caps  in  this  instrument,  if  well 
pushed  home  over  the  openings  of  the  tubes,  prevent  this  from 
occurring. 


2l8  THERAPEUTICS    OF    THE    CIRCULATION 


Description  of  Martin's  Improved  Form  of  Riva-Rocci's 
Sphygmomanometer. * 

The  apparatus  consists  of  a  bag  of  thin  rubber,  Hoth  of  an 
inch  in  thickness,  13^/2  inches  long,  and  4  inches  broad,  the 
interior  of  which  communicates  with  a  piece  of  small-bore 
rubber  tube.  The  rubber  bag  is  covered  on  the  outside  by 
unyielding  leather,  and  loosely  on  the  inside  with  soft  thin 
material.  This  bag  is  wrapped  round  the  arm  over  the  biceps, 
so  that  the  ends  overlap,  and  secured  by  straps,  so  adjusted  as 
to  fit  closely  to  the  arm. 

The  interior  of  the  bag  communicates  by  rubber  tubing  on 
the  one  hand  with  a  mercury  manometer,  and  on  the  other  with 
a  rubber  ball.  A  side  tube  near  the  ball  is  closed  by  a  screw 
and  leather  washer:  by  loosening  this,  the  air  in  the  system 
may  be  allowed  to  escape. 

The  manometer  is  ff.the  ordinary  U-tube  variety,  12  inches 
in  length,  and  made  of  thick  glass  tube.  It  is  provided  with  a 
scale,  which  is  graduated  so  as  to  indicate  the  pressure,  in 
millimeters  of  mercury.  The  glass  tube  is  fixed  to  a  piece 
of  wood,  which  latter  fits  into  a  socket  on  the  side  of  the 
interior  of  the  box. 

The  manometer  can  be  carried  in  any  position,  provided  the 
ends  be  secured  with  the  rubber  caps.  The  whole  aparatus  is 
fitted  into  a  box  in  such  a  way  that  there  is  no  danger  of 
damaging  the  glass  tube. 

One  millimeter  of  the  scale  really  indicates  2  millimeters  of 
pressure  as  the  rise  of  the  mercury  in  one  limb  of  the  manom- 
eter is  accompanied  by  a  corresponding  fall  in  the  other.  This 
is  accounted  for  in  the  marking  of  the  scale  so  that  the  pres- 
sure can  be  read  off  directly  from  the  numbers  on  it  with- 
out the  necessity  for  any  calculation. 

Directions  for  Using  the  Instrument.- — Fix  the  manom- 
eter in  the  socket  and  remove  the  rubber  caps.  Wrap  the  bag 
evenly  round  the  right  arm  of  the  patient,  over  the  biceps, 
either  next  to  the  skin  or  over  soft  clothing,  so  that  the  ends 
overlap.  (With  children  the  bag  can  be  placed  round  the 
thigh.)  Secure  the  bag  by  means  of  the  straps. 

The  arm  and  hand  of  the  patient  must  rest  upon  a  table  at 
the  level  of  the  heart,  and  the  finger  of  the  observer's  left 
hand  be  kept  upon  the  pulse.  Loosen  the  brass  screw  valve 
1C.  J.  Martin,  Brit.  Med.  Journ.,  April  22,  1905. 


APPENDIX    B  219 

near  the  ball,  and  see  that  the  level  of  the  mercury  stands  at 
zero  on  the  scale.  If  this  is  not  the  case,  adjust  the  tube  by 
pushing-  it  up  or  down  until  the  mercury  is  at  this  level. 
Attach  one  end  of  the  tubing  to  the  manometer  and  the  other 
to  the  glass  tube  connection  of  the  bag.  Screw  the  brass  out- 
let-valve tightly  home. 

The  pressure  in  the  bag  is  now  slowly  raised  by  squeezing 
the  ball  with  the  right  hand  until  the  pulse  can  no  longer  be 
felt.  At  this  point  the  rise  of  the  mercury  in  one  limb  of  the 
manometer  is  read  on  the  scale,  and  the  figure  on  the  scale 
indicates  the  maximum  systolic  pressure  at  the  time. 

Having  read  off  the  pressure  in  the  manometer,  allow  the 
air  to  escape  by  loosening  the  brass  screw  near  the  ball.  By 
allowing  the  air  to  escape  slowly,  the  pressure  at  which  the 
pulse  returns  can  also  be  observed. 

The  diastolic  pressure  is  ascertained  by  allowing  the  pres- 
sure to  fall  still  farther  very  slowly,  and  noting  the  height  at 
which  the  greatest  oscillations  of  the  mercury  occur  at  each 
pulsation. 

When  packing  the  manometer  in  its  case,  remove  it  from  the 
socket  and  replace  the  small  rubber  caps  securely  and  tightly 
on  the  open  ends,  to  prevent  the  mercury  escaping.  Then  put 
the  manometer  in  the  guides  at  the  bottom  of  the  box,  face 
upward,  the  scale-end  nearest  to  the  handle.  Upon  this  lay 
the  armlet,  leather  side  upward.  The  tubing,  ball,  etc.,  may 
be  distributed  about  the  case.  Carry  the  box  by  means  of 
the  hand-loop  at  the  end. 

The  scale  on  the  manometer  is  immovable,  but  the  glass 
tube  admits  of  a  small  movement.  Should  any  of  the  mercury 
be  accidentally  spilled,  refill  the  tube,  and  bring  the  surface 
of  the  mercury  to  correspond  with  the  zero  on  the  scale. 
Spilled  mercury  may  be  scooped  up  with  a  bent  calling  card. 
Care  must  be  taken  not  to  use  a  silver  tea-spoon,  which  would 
at  once  become  amalgamated  and  spoiled.  Gold  or  silver  rings 
or  sleeve-links  must  also  be  prevented  from  touching  the 
mercury,  or  they  will  be  spoiled. 

Note. — A  fall  on  the  floor,  or  the  jolting  in  travelling  by 
rail,  may  separate  the  two  columns  of  mercury  in  the  manom- 
eter tube;  to  rectify  this,  hold  the  manometer  board  by  its 
upper  end,  and  gently  swing  it  in  the  manner  adopted  to  ad- 
just the  index  of  a  clinical  thermometer;  leave  the  rubber 
caps  on  the  tubes  whilst  so  doing.1 

1  It  is  made  by  Mr.  T.  Hawksley,  357  Oxford  Street,  London,  W. 


220 


THERAPEUTICS    OF    THE    CIRCULATION 


Lockhart  Mummery's  is  much  like  C.  J.  Martin's,  but  it 
has  a  large  reservoir  of  mercury  like  Riva-Rocci's  original 


FIG.  236.      Lockhart  Mummery's  modification  of  Riva-Rocci's  sphygmomanometer. 
(Made  by   Hawksley.) 

instrument  (page  78),    instead    of  a  U-tube.     The  mercury 

is  retained  by  india-rubber  caps,  and  the  instrument  is  portable. 

Oliver's  New  Sphygmomanometer. — In  this  instrument 


FIG.   237.       Oliver's  new   instrument.      A,  Tap  for   occluding  or   releasing   air;  B, 

tap    for   augmenting   the    oscillations    of   the    fluid    index;    C,    rubber   connections;  D, 

screw    for    regulating    the    pressure    in    the    air    bag;    E,    the    palpating    finger;  F, 
sphygmomanometer. 

the  pressure  is  afforded,  as  in  Hill's  smaller  one  (p.  68),  by 
a  fluid  index  working  against  a  column  of  compressed  air. 


APPENDIX    B 


221 


It  has  the  convenience  of  a  long  scale,  so  that  the  oscillations 
of  pressure  at  every  beat  of  the  pulse  are  very  distinct,  and 
the  diastolic  pressure  (page  82)  is  more  easily  read  than  with 
most  other  instruments.  This  is  made  all  the  easier  by  raising 
or  lowering  the  pressure  by  the  action  of  a  screw,  in  much 
the  same  way  as  in  Gaertner's  tonometer  (Fig.  95,  page  74). 
Gibson's  Clinical  Polygraph. — This  instrument  is  in- 


FIG.  238.  Dr.  A.  G.  Gibson's  clinical  polygraph.  A,  Rectangular  box,  contain- 
ing driving  mechanism  and  electric  time-marker.  Outside  box — Driving  cylinder  C, 
cell  for  strip  of  paper  D.  Pillar  to  hold  three  tambours  and  (a  second)  to  carry  time- 
marking  tambour.  Nos.  i,  2,  3,  4,  are  the  writing  levers  of  the  four  tambours. 
Each  tambour  capable  of  vertical  adjustment  on  its  pillar,  and  an  angular  adjustment 

by  the  screws BB  are  levers  for  throwing  the  pens  out  of  action  when 

filling  with  ink  or  changing  the  paper.  C,  Driving  cylinder.  D,  Cell  to  hold  paper. 
E,  The  adjustable  spring,  keeps  the  paper  flat  against  the  driving  cylinder  when  at 
work.  F  is  the  unwound  coil  of  paper  in  its  cell.  H,  An  axle  carrying  two  friction 
rollers,  adjusted  for  pressure  by  the  screw  at  side.  J,  Screw  to  be  removed  when  the 
time-marker  is  to  be  used.  It  screws  into  the  "  bob  "  of  the  pendulum,  inside  the  box, 
and  keeps  it  in  safety  when  traveling,  etc.  K,  By  screwing  in,  lifts  the  receiver 
away  from  the  pendulum  and  diminishes  the  force  of  impact.  L  is  the  air  tube  of 
the  receiver  inside  the  box,  which  is  struck  by  the  pendulum  "  bob  "  five  times  per 
second.  This  tube  communicates  with  the  writing  tambour  as  shown.  The  stopcock 
governs  the  amount  of  air  passing  to  the  tambour.  MM  are  terminals  for  the  single 
cell  to  drive  the  time-marker.  N  is  an  adjusting  screw  for  the  time-marker,  which, 
when  listened  to,  should  coincide  with  the  ticking  sounds  of  a  watch  held  to  the  ear. 
The  latter  are  five  to  the  second.  P  is  an  ordinary  dry  cell.  Receivers  for  the 
jugular  pulse  and  radial  artery  are  shown  in  situ.  Side  tubes  and  stopcocks  are  for 
regulating  the  air  contents  of  the  receivers;  i.  e.,  a  little  more  or  less  air  may  be 
wanted  in  the  receivers,  and  it  is  easily  blown  in  by  the  mouth,  or  let  out  by  the 
tap.  Both  Oliver's  and  Gibson's  instruments  are  made  by  Hawksley. 

tended  to  give  simultaneous  tracings  of  the  apex  beat,  and 
respiration  of  the  radial  artery  and  jugular  vein. 

A  number  of  other  instruments  might  very  well  have  been 
described  here,  but  I  have  no  illustrations  of  them,  and  without 


222  THERAPEUTICS    OF    THE    CIRCULATION 

illustrations  a  letterpress  description  is  hard  to  understand. 
All  those  instruments  mentioned  in  the  lectures,  of  which  the 
illustration  bears  the  name  of  Ch.  Verdin,  can  be  obtained 
from  his  successor,  M.  Boulitte,  7  Rue  Linne,  Paris. 

Choice  of  Instruments  for  Measuring  Blood  Pressure. 
For  any  one  who  has  only  a  single  instrument,  my  experience 
leads  me  to  think  that  Martin's  new  form  of  Riva-Rocci  is 
at  once  the  cheapest  and  the  best.  If  he  has  more  than  one, 
it  is  very  convenient  indeed  to  use  one  of  Von  Basch's  or 
Potain's,  as  it  is  so  easily  applied.  If  any  doubt  arises, 
Martin's  instrument,  which  is,  I  think,  more  accurate,  can  be 
used  to  control  the  figure  by  Von  Basch's  or  Potain's.  The 
accuracy  of  either  of  these  can  be  tested  with  the  mercurial 
manometer,  as  shown  at  page  83,  but  if  Von  Basch's  instru- 
ment is  employed  as  supplied  by  Down  Bros.,  a  three-way 
stopcock  must  be  got  also,  either  from  them  or  from  Boulitte 
or  from  some  other  maker. 


Exercise  in  Angina  Pectoris. — This  question  came  on  at 
a  late  period  in  the  lectures,  when  I  had  to  deal  with  it  very 
briefly,  but  I  discussed  it  rather  fully  in  my  Harveian  Oration, 
from  which  I  may  take  the  following  quotation :  "  The  cir- 
culation through  the  muscles  is  indeed  a  complex  phenomenon, 
and  it  was  shown  by  Ludwig  and  Sadler  to  depend  at  least 
upon  two  factors  having  an  antagonistic  action.  When  a 
muscle  is  thrown  into  action,  it  mechanically  compresses  the 
blood  vessels  within  it,  and  thus  tends  to  lessen  the  circula- 
tion through  it,  but  at  the  same  time  the  stimulus  which  is 
sent  down  through  the  motor  nerve,  and  which  calls  it  into 


FIG.  239.  After  Ludwig  and  Sadler.  The  marks  along  the  base-lines  indicate 
seconds;  the  height  above  the  base-line  indicates  the  amount  of  blood  flowing  from  the 
veins  of  the  biceps  of  a  dog  during  tetanus  (T  or  tet),  during  rest  (Ruhe),  or  during 
simple  contraction  (Zuck). 

action,  brings  about  a  dilatation  of  the  vascular  walls,  and  thus 
increases  the  circulation  throughout  the  muscle. 

"  When  the  amount  of  blood  is  measured  before,  during,  and 
after  stimulation  of  the  motor  nerve,  it  is  sometimes  found 
that  the  flow  is  diminished,  at  others  that  it  is  increased.  This 
difference  depends  upon  the  comparative  effect  of  the  mechani- 
cal compression  of  the  vessels  of  the  muscles  just  mentioned, 
and  upon  the  increase  of  their  lumen  by  the  dilatation  of  their 
walls.  It  invariably  happens,  however,  that  after  the  muscle 
has  ceased  to  act,  the  flow  of  blood  through  the  muscle  is  in- 
creased. This  increase  is  quite  independent  of  any  alteration 
in  the  general  pressure  of  blood  in  the  arteries,  and  it  occurs 
when  an  artificial  stream  of  blood,  under  constant  pressure, 
is  sent  through  the  muscle.  A  heart  whose  nutrition  has  been 

223 


224  THERAPEUTICS    OF    THE    CIRCULATION 

weakened  by  disease  of  the  arteries,  and  consequent  imperfect 
supply  of  blood  to  the  cardiac  muscle,  is  unable  to  meet  any 
increased  resistance,  if  this  should  be  offered  to  it,  and  pain 
is  at  once  felt.  In  such  cases,  unless  they  be  far  advanced,  we 
find,  precisely  as  we  might  expect,  that  walking  on  the  level 
usually  causes  no  pain,  but  the  attempt  to  ascend  even  a  slight 
rise,  by  which  the  muscles  are  brought  into  more  active  exer- 
tion, brings  on  pain  at  once.  Yet  here  again  we  find,  as  we 
should  expect,  that  if  the  patient  is  able  to  continue  walking, 
the  pain  passes  off  and  does  not  return.  These  phenomena 
would  be  inexplicable  if  it  were  not  for  Ludwig's  observa- 
tions on  circulation  through  the  muscles;  but  in  the  light  of 
these  observations,  everything  is  made  prefectly  intelligible. 
Walking  on  the  flat,  by  causing  no  violent  exertion  of  the 
muscles,  produces  no  mechanical  constriction  of  the  vessels, 
and  thus  does  not  increase  the  blood  pressure.  The  greater 
exertion  of  walking  up  a  hill  has  this  effect;  but  if  the  patient 
is  able  to  continue  his  exertions,  the  increased  dilatation  of 
the  vessels — a  consequence  of  musclar  activity — allows  the 
pressure  again  to  fall,  and  relieves  the  pain." 


APPENDIX  D 

NOTES    BY   PROFESSOR   KRONECKER. 

This  appendix  contains  a  number  of  notes  which  Professor 
Kronecker  has  kindly  sent  me  relating  to  his  own  work  and 
that  of  his  pupils  on  the  heart.  His  notes  are  especially 
valuable,  because  they  afford  such  clear  evidence  of  the  con- 
duction of  stimuli  in  the  heart  by  nervous  channels,  which  it 
is  at  present  rather  the  fashion  to  neglect.  Conduction  of 
stimuli  is  by  many  regarded  as  a  function  of  muscle  only, 
just  as  their  conduction  was  regarded  as  a  function  of  nerves 
only  several  years  ago.  The  truth  probably  lies  between  the 
two  extreme  views,  and  conduction  occurs  through  both  chan- 
nels as  mentioned  at  p.  33.  The  question  is  by  no  means  one 
of  mere  scientific  interest,  because  on  its  correct  answer  a 
correct  knowledge  of  the  causation  and  treatment  of  heart- 
block  depends.  I  have  not  been  able  to  use  the  whole  of  the 
material  with  which  he  kindly  furnished  me,  for  it  arrived 
just  as  this  book  was  going  to  press,  and  to  obtain  the  illustra- 
tions required  would  have  entailed  considerable  delay. 

His  observations  on  self -massage  of  the  heart  and  arteries 
are  also  most  interesting,  for  though  Briicke  (p.  97)  indicated 
the  suction  action  of  the  cardiac  systole,  and  Ludwig  showed 
the  effect  of  muscular  action  on  the  flow  of  lymph  (p.  9),  yet 
it  is  to  Kronecker  that  we  owe  the  first  full  discussion  of  the 
self -massage  of  the  heart  and  arteries. 

The  Work  of  the  Heart. — The  heart  does  not  beat  at  the 
expense  of  its  own  tissues,  but  only  at  that  of  the  energy- 
supplying  material  with  which  it  is  fed.  The  smaller  the 
quantity  of  this  material,  the  less  is  the  work  done  by  the 
heart.  No  other  material  enables  the  heart  to  beat  except 
serumalbumin,  and,  to  a  very  slight  degree,  serumglobulin. 
Only  very  minute  quantities  of  this  are  required,  on  account 
of  the  high  energy-value  of  the  albumen.  Neither  glycogen 
nor  other  carbohydrates  can  supply  the  place  of  genuine 
albumen.  Of  course,  inorganic  solutions  do  not  supply  energy. 
Solutions  of  inorganic  salts,  as  mentioned  by  Gaule,  Binger, 
Howell,  Locke,  Schucking,  and  others,  weakens  the  pulsations ; 
16  225 


226  •  THERAPEUTICS    OF    THE    CIRCULATION 

but  the  better  they  enable  the  albuminates  to  be  utilized  in  the 
heart,  the  less  do  they  have  this  effect.  Every  saline  solution 
gradually  exhausts  the  energy  of  the  heart,  but  it  can  be 
restored  by  serum.  The  blood  corpuscles  and  fibrin  do  not 
take  part  in  this  process,  and  hence  blood  is  no  better  than 
serum  as  a  nutrient. 

Oxygen  does  not  increase  the  work  done  by  the  heart. 
Blood  saturated  with  carbonic  oxide  nourishes  it  just  as  well 
as  arterial  blood.  Asphyxial  blood  is  only  poisonous  on  ac- 
count of  the  CO2  it  contains. 

Dissolved  erythrocytes  (laky  blood)  poison  the  heart  only 
on  account  of  the  poisonous  potassium  salt  set  free  by  their 
solution.  If  these  are  renewed  by  dialysis,  laky  blood  is 
innocuous. 

In  1874  Kronecker  advanced  the  following  explanation  of 
the  ascending  staircase  (Bowditch's  Treppe)  :  The  pulsating 
heart  massages  itself.  In  amphibian  hearts,  where  capillary 
clefts  replace  the  coronary  arteries,  each  systole  presses  out  the 
contents  of  the  clefts,  each  diastole  allows  the  clefts  to  reopen. 
By  this  mechanism  the  nutritive  material  is  renewed.  After  a 
long  standstill  the  products  of  metabolism  remain  in  the  clefts 
and  asphyxiate  the  heart  muscle.  Every  systole  removes  a 
small  quantity  of  the  noxious  substances,  and  their  place  is 
supplied  by  nutrient  material.  In  this  way  we  have  the  para- 
dox of  recovery  through  work.  The  descending  stair  can  be 
artificially  produced  by  washing  out  the  heart  with  saline 
solution. 

Bowditch's  Law. — The  amplitude  of  the  heart's  beats  is 
absolutely  independent  of  the  irritability  of  the  heart.  The 
law  discovered  by  Bowditch  is :  Minimal  stimtili  cause  maxi- 
mum pulsations.  This  law  has  been  thus  paraphrased :  "  all  or 
nothing  " — that  is  to  say,  that  instead  of  a  weak  stimulus 
evoking  a  weak  contraction,  and  a  strong  stimulus  a  strong 
contraction,  any  stimulus  which  will  produce  a  contraction  at 
all  will  produce  as  powerful  a  pulsation  as  the  most  powerful 
stimulus. 

To  this  law  Bowditch  found  two  exceptions : 

(1)  Intermittent  pulsation,  with  constant  regular  normal 
stimulation. 

(2)  Feebler  pulsations  after  longer  rest. 

This  subject  was  more  fully  investigated  by  Kronecker,  who 
succeeded  in  obtaining  a  pulsation  without  fail  on  the  applica- 


APPENDIX  D  22J 

tion  of  each  minimal  stimulus,  if  the  stimuli  were  kept  of 
exactly  equal  strength  by  the  use  of  a  mercurial  contact  kept 
perfectly  clean  by  a  constant  stream  of  water. 

He  also  showed  that  the  first  pulsations  after  rest  were  not 
smaller  than  the  later,  if  the  contents  of  the  heart  were  kept 
fresh  during  rest. 

Thus  he  proved  that  Bowditch's  law  holds  good  without 
any  exception. 

Refractory  Period. — More  important  still  was  Kronecker's 
discovery  that  the  heart  is  not  irritable  during  systole.  Many 
called  this  the  refractory  period.  Even  after  the  systole  is 
over,  the  heart  only  gradually  regains  its  irritability.  Tem- 
perature modifies  the  irritability  of  the  heart  to  a  great  extent. 
He  found  that  at  a  temperature  of  30°  C.,  a  heart  can  be  made 
to  beat  sixty  times  a  minute  by  induction  currents  of  15  units 
(Kronecker)  and  the  contracture  augments.  When  cooled  to 
8°  C.,  it  can  beat  twelve  times  per  minute;  at  5°  C.,  only  six 
times  per  minute,  even  when  12  stimuli  of  30  units  each  are 
applied.  Every  pulsation  lasts  about  5  seconds  so  that  the  new 
systole  begins  after  5  seconds  of  diastole. 

This  curious  reaction  of  the  heart  to  frequent  (intermitting) 
stimuli  explains  why  the  heart  cannot  be  tetanized. 

The  frog's  heart,  at  a  temperature  of  30°  C.,  and  stimulated 
forty  to  fifty  times  per  minute,  makes  a  pulsation  every  second. 
At  a  medium  temperature,  15°  C.,  it  pulsates  about  every 
second  second.  At  a  low  temperature,  10°  C.,  it  beats  about 
every  fifth  second,  although  the  pulsation  only  lasts  2.5  sec- 
onds. In  the  cold  heart  the  duration  of  the  pulse  is  6  seconds, 
but  the  heart  only  regains  its  irritability  again  after  15  sec- 
onds. This  behavior  of  the  frog's  heart  supplies  an  explana- 
tion of  the  fact  that  constant  stimuli,  such  as  chemical  ones, 
have  an  intermitting  effect.  Within  the  last  few  years,  Kro- 
necker and  his  pupils  have  found  that  the  ventricle  of  the 
frog's  heart  ceases  to  beat  if  its  contents  are  deprived  of  all 
stimulating  properties.  Thus,  Algina  found  that  a  ventricle 
would  remain  without  beating  for  an  hour  and  a  half  at  a  time 
for  as  long  as  three  days,  when  it  was  supplied  with  sheep's 
serum  which  had  been  dialyzed,  neutralized,  and  then  brought 
up  to  0.6  per  cent,  of  sodium  chloride  contents. 

It  would  therefore  seem  that  there  is  no  true  automatism 
in  the  ventricle,  but  only  intermittent  action  to  a  constant 
stimulus. 


228  THERAPEUTICS    OF    THE    CIRCULATION 

Coordination  of  the  Heart-Beats. — Two  opposite  views 
are  held  by  physiologists  in  regard  to  this  subject. 

Those  who  hold  the  myogenic  view  consider  that  the 
muscular  cells  which  form  the  cardiac  wall  transmit  a  stimulus 
from  one  to  another.  But  Kronecker  and  Irachanitzky1  made 
the  following  observation,  which  seems  to  show  that  this  is  not 
the  case.  Microscopic  preparations  of  rabbits'  hearts  fixed  in  a 
state  of  fibrillation  show  that  the  condition  of  irritation  does 
not  pass  the  limits  of  the  cell.  Preparations  of  hearts,  which 
were  fixed  while  the  pulsations  were  normally  coordinated, 
exhibit  equidistant  stria.  Coordination  is  effected  by  nu- 
merous plexuses  of  non-medullated  nerves.  As  soon  as  these 
are  paralyzed,  the  heart  falls  into  an  irregular  kind  of  motion, 
either  fibrillary  or  peristaltic. 

The  nerve  centers  of  the  heart,  like  those  of  the  brain,  con- 
sist of  groups  of  ganglion  cells  and  nerve  plexuses.  These  are 
quickly  paralyzed  by  want  of  blood. 

Fibrillation  occurs  in  the  heart — 

1.  If  the  coronary  arteries  are  ligatured. 

2.  If  small  branches  of  the  coronary  arteries  are  plugged 

by  embolism  (reflex  effect). 

3.  If  the  heart  is  tetanized. 

4.  If  the  mammalian  heart  is  quickly  cooled  down  to  about 

25°  C. 

5.  If  the  ventricular  septum  is  punctured  about  the  junction 

of  the  upper  and  middle  third. 

6.  Sometimes  by  the  rapid  application  of  chloroform. 
Rabbits'  hearts  in  a  state  of  fibrillation  may  spontaneously 

commence  to  beat  rhythmically.  Dogs'  hearts  (except  when 
the  animals  are  very  young)  continue  to  fibrillate,  and  die 
unless  they  are  saved  artificially.  Dogs'  hearts  may  be  saved 
from  a  state  of  fibrillation — 

(1)  By  very  strong  electric  shocks    (240  volts),   applied 
directly  to  the  heart  (Batelli  and  Prevost). 

(2)  By  heating  to  43°  C.  or  45°  C. 

(3)  By  chloral-hydrate  (Barbera). 

If  the  roots  of  the  coronary  arteries  have  been  ligatured, 
they  cannot  be  saved. 

Kronecker  succeeded  in  reestablishing  pulsation,  but  only 

1  Archiv.  Internation.  dc  Physiol.,  vol.  iv.,  p.  i,  July,  1906.  This  paper 
•contains  a  very  complete  resume  of  the  literature  on  the  subject  of  the 
channels  through  which  stimuli  pass  from  one  part  of  the  heart  to  another. 


APPENDIX  D  229 

on  the  right  ventricle  of  the  dog's  heart,  in  the  following  ex- 
periment. He  ligatured  the  anterior  root  of  the  coronary 
artery;  they  produced  fibrillation,  and  finally  conducted  a 
strong  current  of  240  volts  through  the  heart.  From  this  he 
concluded  (i)  that  narrowing  of  the  coronary  arterial  system 
paralyzes,  either  -directly  or  reflexly,  the  coordinating  nervous 
system  of  the  heart;  (2)  that  the  paralysis  may  be  removed 
by  producing  dilatation  of  the  coronary  arteries  by  heat, 
chloral-hydrate,  or  electric  currents  of  high  intensity;  (3)  that 
a  center  for  the  innervation  of  the  coronary  vessels  lies  in 
ventricular  septum.  At  the  point  in  the  ventricular  septum 
where  puncture  produces  fibrillation,  no  ganglion  cells  are  to 
be  found,  but  only  nerve  plexuses,  which  have  a  similar  func- 
tion as  ganglia. 

Conduction  of  Stimuli  from  Auricles  to  Ventricles. 
When  the  heart  is  beating  normally  the  two  auricles  are  seen 
to  contract  simultaneously,  and  the  same  is  the  case  with  the 
ventricles.  The  coordination  between  the  auricles  and  ven- 
tricles is  such  that  they  begin  their  contraction  in  regular  inter- 
vals, so  that  the  completion  of  systole  in  an  auricle  is  followed 
without  any  interval  by  the  commencement  of  the  systole  of 
the  ventricle. 

Such  coordination  is,  like  the  act  of  swallowing,  only  pos- 
sible through  central  nervous  arrangements. 

Those  W7ho  hold  the  myogenic  theory  say  that  the  relaxa- 
tion occurs  on  account  of  the  specific  structure  of  the  muscle. 
This  is  not  to  be  found  in  the  frog's  heart.  In  the  mammalian 
heart  the  retarded  conduction  is  ascribed  to  the  bundles  of 
Stanley-Kent  and  His. 

Kronecker  and  Imchanitzky  have  showed  that  this  bundle 
can  be  ligatured  without  disturbing  the  coordination  between 
auricles  and  ventricles. 

Dr.  Paukul  of  Dorpat,  while  working  recently  in  Professor 
Kronecker's  laboratory,  found  that  the  Stanley-Kent  and  His 
bundle  of  muscular  fibers  connecting  the  auricles  and  ventricle 
is  accompanied  by  nervous  plexuses,  injury  of  which  disturbs 
coordination,  whilst  ligature  of  the  muscular  part  of  the  bun- 
dle does  not  impair  coordination. 

Dr.  Imchanitzky,  also  working  under  Kronecker's  direction, 
discovered  in  the  hearts  of  lizards  two  nerves  with  immense 
groups  of  ganglia  uniting  the  auricle  with  the  ventricle.  When 
these  were  ligatured,  the  coordination  between  the  beats  of 
the  auricle  and  ventricle  was  destroyed. 


230  THERAPEUTICS    OF    THE    CIRCULATION 

Dr.  Lomakina  several  years  ago  observed  disturbance  of 
coordination,  after  the  application  of  ligatures  to  the  hearts 
of  dogs  and  rabbits  at  points  where  the  bundle  could  not  be 
injured — e.  g.  to  the  pulmonary  artery  at  its  exit  from  the 
right  ventricle. 

Kronecker  often  saw  incoordination  occur  on  the  applica- 
tion of  a  ligature  to  the  right  ventricle  at  the  point  where  the 
vense-cavae  inosculate.  How  is  it  possible  on  the  myogenic 
theory  to  explain  the  occurrence  of  fibrillation  in  the  tetanized 
auricles  while  the  ventricles  are  pulsating  normally  or  vice 
versa  ? 

Is  His's  bundle  then  in  a  state  of  fibrillation  and  yet  effect- 
ing pulsations?  Kronecker  also  showed  that  the  vagi  when 
stimulated  can  inhibit  the  ventricles  whilst  they  do  not  affect 
the  fibrillating  auricles. 

How  can  this  fact  be  explained  otherwise  than  on  the  hy- 
pothesis that  the  nerves  conduct  the  inhibition  through  the 
fibrillating  muscular  masses? 

The  cardiac  vagi  do  not  act  on  cavities  of  the  heart  which 
are  under  the  influence  of  local  stimulation.  A  ventricle 
through  which  normal  saline  solution  is  being  circulated  can- 
not be  stopped  by  stimulation  of  the  vagus,  but  if  the  ventricle 
is  supplied  writh  Ringer's  solution  or  blood  stimulation  of  the 
vagus,  it  produces  its  ordinary  inhibitory  effect.  The  same 
minimal  stimulus  which  will  cause  the  ventricle  in  a  state  of 
ordinary  rest  to  pulsate,  suffices  to  produce  a  pulsation  in  an 
inhibited  ventricle.  The  vagus  is  therefore  not  an  anabolic 
nerve. 

Conduction  of  Stimuli  in  the  Heart. — In  a  paper  on  this 
subject  from  Kronecker's  laboratory,  D.  Maria  Imchanitzky 
(Archives  Internationales  de  Physiologic,  vol.  iv.,  p.  I,  July, 
1906)  gives  a  very  full  abstract  of  all  the  literature  on  the 
subject,  and  a  resume  of  the  results  of  original  experiments 
made  under  Kronecker's  direction.  These  are : — 

I.  From  the  histological  researches  it  appears : — 

(a)  That  the  muscular  cells  in  the  ventricles  of  the  heart 
in  repose  or  in  coordinated  action  present  everywhere  the 
same  histological  appearance,  the  striation  being  identical 
everywhere. 

(&)  When  the  heart  is  fixed  in  a  state  of  fibrillation,  the 
cells,  on  the  contrary,  present  different  aspects.  The  state  of 
striation  differs  from  one  cell  to  another.  The  intercellular 


APPENDIX  D 


23I 


limits  generally  form  sharply  marked  dividing-  lines  between 
a  cell  with  striae  widely  apart  and  another  with  them  close 
together,  although  sometimes  these  different  appearances  can 
be  found  in  one  and  the  same  cell.  (See  Fig.  240.) 

(c)  From  the  aspect  of  these  structures  one  must  conclude 
that  the  contraction  does  not  pass  from  one  muscular  cell  to 
another,  but  that  the  stimulation  is  transmitted  by  coordinating 
nervous  communications. 

II.  Experiments    made   by   ligaturing   the   bundle   of    His 


FIG.  240.  Cells  taken  from  a  heart  in  fibrillation.  The  preparation  shows  that  the 
intercellular  limits  separate  very  sharply  parts  with  striae  widely  apart  from  others  with 
striae  close  together,  whilst  in  the  interior  of  the  cells  numerous  transitions  may  be 
observed.  The  larger  figure  is  magnified  750  diameters  by  an  apochromatic  objective, 
No.  2  of  Zeiss,  and  compensating  eyepiece,  No.  6.  The  small  portion  strongly  magnified 
was  observed  with  Zeiss's  No.  2  objective  and  a  compensating  eyepiece,  No.  18,  with  an 
intense  illumination. 

prove  that  hearts  may  exhibit  coordinated  pulsations  of  the 
auricles  and  ventricles  after  the  destruction  of  this  bundle. 

Importance  of  the  Pulse  for  the  Current  of  Blood  in  the 
Arteries. — In  experiments  made  with  his  pupil,  Dr.  Gustav 
Hamel,1  in  which  nutrient  fluid  was  perfused  through  the  blood 

1  Zcitschrift  f.  Biologic,  Ed.  xxv.,  X.  F.,  vii.,  p.  4/4. 


232  THERAPEUTICS    OF    THE    CIRCULATION 

vessels  of  a  frog,  Kronecker  found  that  when  the  flow  was 
interrupted  rhythmically  by  a  stopcock  worked  by  an  electric 
pendulum,  the  vessels  allowed  much  more  fluid  to  flow  through 
them  than  when  the  flow  was  continuous.  The  advantage  of 
the  rhythmical  impulse  appears  to  consist  in  this :  that  the 
alternate  movements  maintain  the  elasticity  of  the  arteries  and 
the  pauses  serve  for  recuperation  of  their  muscular  walls.  The 
intermitting  rest  is  certainly  of  great  value  to  the  vascular 
walls,  for  when  they  are  subjected  to  continued  pressure  they 
are  injured  and  allow  fluid  to  exude  into  the  tissues  and  pro- 
duce cedema.  On  the  other  hand,  when  the  flow  is  rhyth- 
mically interrupted,  very  little  cedema  appears  (cf.  p.  128). 
The  cardiac  pulsation  acts  like  an  internal  massage,  and  by 
producing  passive  gymnastics  maintains  the  cohesion,  elas- 
ticity, and  contractility  of  the  arteries. 

Circulation  in  the  Splanchnic  System. — In  1889  Kro- 
necker showed  at  the  Naturforscherversammlung,  in  Heidel- 
berg, that  normal  saline  solution  flows  readily  into  the  portal 
venous  system  of  a  rabbit  under  a  pressure  equivalent  to  30 
centimeters  of  water.  When  the  portal  vein  is  ligatured  close 
to  the  hilus  of  the  liver,  the  saline  solution  only  begins  to 
enter  under  a  pressure  of  60  centimeters.  But  if  the  abdominal 
aorta  is  ligatured  close  to  the  diaphragm,  and  above  the  ab- 
dominal arteries,  the  veins  become  paralyzed,  and  allow  enorm- 
ous quantities  of  saline  solution  to  flow  into  them  under  a  very 
low  pressure. 


INDEX. 


NOTE. — In  this  index  the  numbers  of  the  figures  referred  to   are  not  given,  but  only 
the  pages  on  which  they  may  be  found. 


ABDOMEN,  blow  on,  shock  due  to — twofold 
action — Goltz's  experiments  on  frog, 
showing,  1 13 

—cold  wet  compress  applied  to — beneficial 
in  sleeplessness — why,  175 

— constriction  of,  by  corsets  or  belts,  risks 
from,  141 

— extra  pressure  on,  when  thighs  are 
swollen,  133 

- — serous  cavity  of,  effusion  into — Tap- 
ping to  remove,  204 

Abdominal  distension  (see  also  stomach, 
distention  of),  mechanical  interfer- 
ence by,  with  lungs  and  heart,  131, 
138 

• — massage,  flatulence  lessened  by — how, 
138 

- — vessels,  contraction  of,  due  to  severe 
pain — circulation  maintained  by,  113 

— viscera,  duty  of  the  diaphragm  to,  in 
upright  and  in  recumbent  positions, 
133 

Abscess,  cerebral — bradycardia  in  connec- 
tion with,  187 

Absorbent  cotton  wool — use  of,  in  tap- 
ping, 204 

Absorption,  drugs  causing,  useful  in  cases 
of  high  blood-pressure  due  to  gouty 
kidney,  101 

• — fluid  supplied  by,  replacing  that  drawn 
from  blood  by  kidneys  in  oedematous 
diseases  of  the  heart,  150,  152 

• — of  oedema,  ascites,  or  pleural  effusion, 
effected  by  rest  and  massage,  138 

Accelerators,  probable  effect  on,  of  atro- 
pine,  107,  note 

— stimulation  of,  deduced  from  pulse- 
rate  in  exophthalmic  goitre,  107 

Accessory    muscles    of    circulation,    7 

Acidity  of  stomach,  aggravation  of  drowsy 
sleeplessness  of  cardiac  disease — how 
relieved,  193 

Acocanthera  (Oubain),  action  of — not 
used  in  medicine,  146 

Aconite — typical  cardiac  depressant,  char- 
acteristic physiological  action  of,  171 

— effect   of,    on    frog's   heart,    171 

in  local   inflammations,    172,    174 

in   nervous   flutterings  of   heart,    172 

in  high  tension   in    angina  pectoris,.  174 

• on    mammals,    in    large    and    in    small 

doses,  171 
— on  very  rapid  pulse,    166 

Acute  anaemia,  fatty  degeneration  of  the 
heart  in,  100 

Acute  disease,  sequelae  of,  dilatation  of 
the  heart  in,  126 

— rheumatism — bradycardia  with  weak 
heart  in  convalescence  from,  186-7 

Adami,   see   Roy  &   Adami 

Adonis  rernalis  (pheasant's  eye),  uses  of, 
146 


Adrenaline,  action  of,  on  heart  and  ves- 
sels, 1 60 

Adult  (s)  heart,  action  on,  of  Digitalin, 
147 

not    injured    by    moderate    smoking — 

double    action    of    smoking    in,     169 

After-cure,  subsequent  in  Nauheim  treat- 
ment, 20 1 

Age,  see  elderly,  old  age,  senile,  and 
senility 

Agurin,  nature  and  uses  of,   162 

Albumen  in  urine,  disappearance  of,  due 
to  rest  and  massage,  139 

— effect  on,   of  mercury,   208 

in     sleeplessness     in     cardiac     disease 

not     centra-indication     of     use     of 
opium   or   morphine,    195 

Albuminuria,  a  consequence  of  venous 
engorgement,  129 

• — use   in,   of  mercury — author's  view,   208 

Alcohol,  bradycardia  sometimes  caused 
by — how,  109,  187 

— effect  of,  on  medusae  (contractile  tis- 
sue), 30-31 

— excessive  use  of,  as  cause  of  palpita- 
tion— to  be  cut  off  or  docked,  179 

— ingestion  of  large  quantities  causing 
speedy  death — analogy,  113 

Alcoholic  neuritis,  paralysis  of  the  vagi 
due  to — rapidity  of  pulse  after,  107 

Alcoholism,  chronic,  fatty  degeneration 
of  the  heart  in,  100 

Alkalies,  form  of  bradycardia  in  which 
suitable,  188 

Aloes,  as  aperient,  in  senile  rise  of  pres- 
sure— how  taken,  208 

American  modifications  of  Riva-Rocci's 
instrument,  79,  80,  81 

Amoeba,    contraction   in,   of  vesicle,   27 

Ammonia  liniment  over  cardiac  region, 
extremely  stimulating  action  of,  178 

Ammonium,  bromide  of,  in  Graves's  dis- 
ease— effects  of,  184 

— Hippurate  (Oliver),  in  treatment  of 
high  tension,  208 

Amyl  nitrite,  efficacy  of,  as  vascular  dila- 
tor, 165 

— in    angina    pectoris,    208 — special    ad- 
vantages,   189,    (figs.)    190 

in    cardiac    asthma,    less    useful    than 

in   angina — why,    193 
— investigations    on,    of    Guthrie,    etc., 

and  of  author,    163 
— -overdoses  of,  sole  ill-effect  from,   191 

Anaemia,  acute  and  chronic,  fatty  degen- 
eration of  the  heart  in,  100 

— bradycardia   associated   with,    186 

— dilatation   of  the  heart  in,    126 

— of  the  brain,  sudden,  probable  cause  of 
syncope,  1 14 

• — of  the  tissues  with  temporary  contrac- 
tion of  arteries,  in  Raynaud's  dis- 
ease, 117 


233 


234 


THERAPEUTICS    OF   THE    CIRCULATION 


Anaesthesia,  imperfect,  fatal  shock,  how 
caused  by — author's  view,  113-4 

Anaesthetics,  tight-lacing  dangerous  dur- 
ing administration  of,  141 

Ancients,  the,  views  of,  on  circulation 
and  arteries,  basis  of,  2. 

Aneroid  manometer,  Gaertner's — portable 
form  of  his  tonometer,  76,  (fig.)  76 

• — sphygmomanometer,  author's  apparatus 
for  standardizing,  83 

Aneurism,  indicated  by  louder  second 
heart  sound,  42 

— cerebral,  bradycardia  in  conjuction 
with,  187 

Anger,  angina  pectoris  due  to — historic 
fatal  case,  189 

Angina  pectoris,  difficulty  of  making  ob- 
servations in — author's  recorded,  121, 
and  note 

— high  tension  in,  aconite  sometimes  use- 
ful in — precaution  advised,  174 

— claudication  in,    Brodie   cited  on,    116 

— in  relation  to  contraction  of  coronary 
arteries,  116,  189 

— liability  in,   to  sudden  death,    196 

• — pain    of — causes,     116,     121,    and    note, 

123,    189 

— location  and  extent,   189 
— severity   of,    121 

— pain  simulating,  due  to  over-smoking, 
170 

— sensations  akin  to,  in  paroxysmal  tachy- 
cardia, 108 

— sensations    frequent   in    (see   Pain) 
— (a)    intense  oppression,    121 
— (b)   extreme  pain,  121 — nature  of  the 
latter  in   author's  view,    121-2,    and 
note 

(c)    anxiety,    122,    note 

— treatment  and   relief  of — aims  of,  189-90 
— during   attacks,    191 
— during   intervals,    ib. 

amyl   nitrite   in,    208 

-author's    successful    use    of,    164-5 


— bleeding,    175,    177,   208 
— cold    bandages — application    of,    effect 
on  radial  artery,  175,  177,  (fig.)  176 
— diet  and   regimen  in,    191-2 
Angio-neurotic  oedema,   conditions  of,    153 
— no   venous   obstruction   in,    153 
— pathology     not     made     out — author's 

view,   1 1 8 
Animal,    an,    "  bled    into    its   own   veins," 

Ludwig    cited   on,    16 
Animals,    blood-pressure   in,    60 
— poisoned    by   digitalis,    apex-beat   in,    in- 
creased,   I  12 
— slain    for   sacrifice,    arteries   empty   in — 

reason,    2,    5 
Antiaris  to.ricaria.  or  upas,  action  of,  not 

used   medicinally,    146 
Antiseptics,    in    treatment   of   toxin-caused 

bradycardia,    188 
Anti-streptococcic  serum — universal  cedema 

brought   on   by   injection   of,    118 
Anxiety,    in    angina    pectoris,    121,    note 
— effect  of,  on  the  circulation,    104 
— oppression  of  chest,  caused  by — to  what 

due,    121 

Aorta,    blood-pressure    in,    in    mitral    in- 
competence,   127 
— composition    of,    44 
— contractile   power   of,    44 
— in    elderly     people,     atheromatous    and 
rough   with    systolic   murmur,   but   re- 
gurgitation    not   necessarily    resulting, 

122 


Aorta,  investigation  of,  with  Marey's 
cardiograph  —  results,  86-90,  (figs.) 
86,  88 

— relative  resistance  of,  44 
Aortic  bulb,  frog's  heart,   19 
• — cartilage,     aortic     regurgitant     murmur 

usually  well   heard  over,    195 
— disease,     liquid     allowed     in,     by     Dr. 

Schott,    20 1 
• — incompetence — causes — consequences, 

122-3 

• — orifice — narrowing    of,     due    to    inflam- 
mation  during  foetal  life,   or  to  vege- 
tal growths  in   later  years,    122 
— pulse,    tracings    of,    with    Marey's    car- 
diograph,  89,    (figs.)    88 
— regurgitation,     patients     with,     arterial 
pulsation    observable    in — coincidence 
of  the  three   rhythms  in,   47 

as   affecting   snhygmograms,   9° 

full  diet  advised  in,  by  Dr.   Schott — 

why,   20 1 

— how   recognized,    122-3,    "95 
— left   ventricle    yielding    before    strain 
— consequences,      196 — danger     of, 
and   treatment,    196-7 

liability    in,    to    sudden    death,    196 

— murmur  of,   43,   place   where   heard — 
caution    on — case   illustrating,  195-6 

process,  causes  and  results  of,    122 — 

aspect  of  those  affected  by,    122-3 
— risk   of  syncope   in,    196 
— uncomplicated,   effects  of  digitalis  in, 
alone,     and     in     combination — risks 
from,    196 

— use   of  digitalis,    strychnine,    and   caf- 
feine  in,    196,   203 
Aortic    stenosis,     how    recognized,     122-3, 

195 
• — valves,       aortic       regurgitant       murmur 

usually   well    heard   over,    195 
— closure    of,     cause    of    second    sound 

(Williams),   41 

destruction    of,    bruit   or   murmur   re- 
sulting   from,    43 

stiffness  of,  with  years — consequence, 

122 

vegetal  growths  on — consequence,  122 

Aperients    (see  also   Purgatives),   in  cases 

of  senile  rise   of   pressure — how  taken, 

208 
Apex  of  heart,   angina  pain  felt  towards, 

189 
— frog's,    dilatation    of,    by   pressure    from 

within,   28,    128 

point   of  chest   wall   over,   first  sound 

of  heart  best  heard  at,  42 
Apex-beat,       Burdon-Sanderson's      cardio- 
graph for,    (fig.)   86 
— in   palpitation  of  the  heart,    112 
Apocynum   cannabinum  (Canadian   hemp), 

uses  of,    146 
Appetite,      improved,      in      absolute      rest 

treatment,    by   massage— why,    138 
— lessened     by     disordered     circulation — 

why,    131 

Apoplexy  (ia),   brain-pressure  due  to,  caus- 
ing  bradycardia — how,    109 
— causes  of,   14,    15 
— cerebral — common     in     advanced     life — 

cause,      205-6  — •  possible      means      of 

averting,    208-9 
- — risk     of,     in     cases     of     arterio-capillary 

fibrosis,   due  to  kidney  disease,    101-2 
— risk    of    causing,    by    Digitalis    in    cases 

of   fatty   heart — why,    162-3 


INDEX 


235 


Archangelsky,  views  of,  on  importance  of 

cardiac  ganglia,  32,  note 
Arm(s),    application    to,    of    cold    bandage 
• — effect    of,    on    radial    artery,     175, 
(fig.)    176 
— bend    of,    source    of   blood    at,    author's 

deductions  from,  as  to  syncope,   115 
—bleeding     from — cases    in    which    bene- 
ficial,   175,    208 

—  (specially  left  arm),  affected  by  an- 
gina pain,  189 

—volume  of   reduced,    during   hard   think- 
ing— Mosso's   demonstration,    114 
Arrow-poisons,     also     used     similarly     to 

digitalis,    146 
Arsenic,    fatty    degeneration    of   the   heart 

found   after   administration   of,    100 
Arterial    circulation,    as    assisting    venous, 

6,    99,    102 

— massage  of  the  nerves,   in   health,  135 
• pulsation,     coincident     with     respira- 
tion, 46 

• — runture,  risk  of,  from  rise  of  blood- 
pressure  in  chronic  interstitial  ne- 
phritis, 49,  50 

Arterial  tension  (see  also  blood-pres- 
sure), 10 

instrument   for   estimating,    suggested 

combined    use    of,    with    sphygmo- 
graph,  94 

rnitroglycerine    the    stock    remedy    for 

lowering — how    administered,    165-6 

quickened   pulse,    and   pain   of   angina 

pectoris,     relations     between — cases 
illustrating,    121,   and   note 
high,     in     advanced    age — diet,     regi- 
men, and  medicines  prescribed  for, 
208-9 — risks     of,     with     antheroma- 
tous  arteries,    206-7 
— in      angina     pectoris — relation     be- 
tween   and    the    pain,     121,    and 
note,   174,   189 

— in   Bright's   disease,   90,    (fig.)    88 
— in     attacks     of     paroxysmal     tachy- 
cardia,  calling   for  vascular  dila- 
tors,   185 

— indicated    by    louder    second    heart 
sound,   42 

high  ana  low,    as  affecting  first  heart 

sound,    43 

— regulation  of,   13-15 

Arterial    walls,     degeneration    of,    in    the 
aged,     conditions    and     consequences, 
89,   99,    100,   101,    116,  205,   206-7 
Arterialized    blood,     first    portion    of,    re- 
ceived by   coronary   arteries,   94 
Artery(ies),    see    also    under   Names 
— as  affected  by  old  age,  89,  99,  (fig.)  98, 
100,    101,     1 1 6,    206-7;    timely    atten- 
tion  to,    a  means  of   prolonging  life, 
205 
— of     brain — as     affected     by     Raynaud's 

disease,    117 

— in    cases    of    aortic    regurgitation,    irri- 
tability  of,    and   tendency   to   rhythm- 
ical  contraction  in,   46,    123 
— contractile  force  of,  to  what  due,   work 

done  by,    10-11 

— contraction    of,    due    to    digitalis,     148, 
how    effected,     149 — due    to    local    ap- 
plication of  cold,    175,    (fig.)    176 
— in   old  age — consequences,    116 
— temporary,     in     Raynaud's     disease — 

consequences,    117 

• — diastolic  and  systolic  pressure  in,  how 
estimated,  71,  (fig.)  70 


Arteries,   elastic   recoil   of,   4 

as    affected    by    age,    89,     116,    205, 

(fig.)    88 

as    affected    by    Bright's    disease,    90 

(fig.)    88 
— in   relation   to  contractile   force,    10 

— emptiness  of,  causes  of,  2,  5,  90 

— of  head  and  neck,  peripheral  contrac- 
tion of,  with  central  dilatation  the 
cause  of  migraine,  in  author's  view, 
119 

— with  impaired  elasticity,  tracings  yielded 
by,  89,  (fig.)  88 

— internal,  as  affected  by  Raynaud's  dis- 
ease, 117 

— large,  alterations  in,  in  relation  to  mi- 
graine, 119-20 

— massage  by,   of  nerves,    134 

— of  moderate  size,  alterations  in,  in  re- 
lation to  migraine,  1 19-20 

— motor    and    peristaltic    action    of,    5 

— ossification  of  (or  obliteration),  angina 
pectoris  and  claudication  due  to 
(Brodie),  116 

— periodical  pulsation  in,  observable  in 
patients  with  aortic  regurgitation — 
coincidence  of  the  three  rhythms  in, 
46-7 

— renal,    effects    on,    of    ligature    of,    and 
•  similar  effect  of  digitalis,  etc.,   155-6, 
162 — how   overcome,    163 

— self-massage   of,    process  and   value   of, 

6,   99,    102 
— increased   by    digitalis,    149 

by  massage  and  exercises,   202 

—sensitiveness  of,    119 — how   proven,    120 

• — single,  compression  of,  to  measure  hu- 
man blood-pressure,  instruments  for 
- — 60  et  seq.,  (figs.)  60-67 

— size  of,  Oliver's  arteriometer  for  meas- 
uring, 83 

— three  functions  of,  4 

—  (i)   storers    of    force,    ib. 

—  (2)    regulators,    ib. 

—  (3)   motors,  ib. 
Arteries    and    capillaries,    45 

— blood  entering  and  leaving,  need  of 
balance  between: — results  of  upset- 
ting, 13-15 

Arterio-capillary  fibrosis  (Gull  &  Sutton), 
nature,  causes,  and  results  of,  101 

Arterioles,  contractibility  of,  probable 
effect  of,  10 

— contraction  and  dilatation  of — causes, 
45-6,  118 

due  to  nicotine — how  caused,    167 

transverse,  suggested  as  possible,  45, 

(fig.)  46 

— effect   on,    of   digitalis,    146 

of  high  tension  in  chronic  interstitial 

nephritis,  49 

— frog's — dilatation  in,  caused  by  local 
irritation,  observed  by  Gunning  & 
Cohnheim,  46 

— importance  of,  pointed  out  by  author 
in  thesis  of  1866,  157 

—increased  peripheral  resistance  in,  dan- 
gers from,  101 

— irritation  of,  local — author's  observa- 
tions on  effect  of,  46 

— lumen  of,  lessening  of,  risks  of,  and 
some  causes,  101 

— muscular   layer  in,   45 

— nervous   fibrils   in,   45 

— small,  and  capillaries,  diseases  in  which 
chiefly  affected,  117-8 


236 


THERAPEUTICS    OF   THE    CIRCULATION 


Arterioles  of  submaxillary  gland — effect  on 
of  irritation  of  chorda  tympani — -par- 
allel, 115 

Arterioles  and  veins,  nerves  of — observa- 
tions on,  of  Brunton  &  Schweigger- 
Seidel — results,  45 

Arteriometer,    Oliver's,    use   of,    83 

Arterio-sclerosis — diffuse,  or  arterio-capil- 
lary  fibrosis  (Gull  &  Sutton),  nature, 
causes,  and  results  of,  100-1 

• — nodular,   how  induced,    101 

Artificial  circulation — Ludwig's  invention 
and  methods,  143,  (fig.)  142 

Ascites,    removed    by    rest    and    massage, 

.    139 
- — in    venous    engorgement — how    induced, 

129 
— with  flatulence,  effect  of,  on  the  heart, 

131 

— without  flatulence,    rare,    139 

Ashanti  campaign,  value  of  beef-tea,  etc., 
as  stimulants,  shown  in,  by  Parkes, 
145,  and  note 

Ashes,  and  waste  products  of  tissues — 
parallel,  145 

Asphyxia,  local,  in  Raynaud's  disease — a 
parallel,  117 

Assimilation,  improved,  due  to  lessened 
venous  congestion  caused  by  digi- 
talis, 153-4 

Asthma,  cardiac,  causes  —  symotoms — 
treatment,  192-3 

— spasmodic,  permanent  dilatation  of 
right  side  of  heart  due  to,  130 

Atheroma,  aortic,  indicated  by  louder 
second  heart  sound,  42 

• — blocking  by,  of  arteries,  results  of,  sim- 
ilar to  those  caused  by  cerebral  hem- 
orrhage, 205 

of    arteries,    consequences,    205 

— of    coronary    artery — consequences,    96 

• — of  right  pulmonary  artery  —  conse- 
quences of,  130 

Atheromatous  button,  formation  of,  how 
induced,  101,  (fig.)  98 

Atheromatous  arteries  of  old  people,  89, 
115,  205,  (fig.)  98 

danger   of,   with   high   blood-pressure, 

205 

Atheromatous  ulcers,  in  arterial  walls  in 
old  people — provoking  causes,  101 

Atonic  condition  of  embryonic  heart,  in- 
duced by  drugs  retarding  oxidation, 
148 

Atrophy,  brown,  causes  of,   100 

Atropine,  effects  of  digitalis  on  frog's 
heart,  not  overcome  by,  147 

— paralysis  of  vagi  caused  by — pulse-rate 
after,  107 — -probable  action  of  the 
drug,  107,  note 

Auricular  beats  in  frog's  heart,  as  af- 
fected by  stimulation,  34,  (fig.)  35 

Auricle,    hypertrophy   of,    caused   by 

mitral   obstruction,    127-8 

mitral    regurgitation,    127 

— right,  dilatation  and  hypertrophy  of — 
venous  engorgement  due  to,  129 

Auricles  in   frog's  heart,    19 

• — electric  stimulation  of,  effects  of 
(Brunton  and  Cash),  34,  (fig.)  35 

Auriculo-ventricular  orifices,  muscular 
fibers  round,  aid  given  by,  to  valves, 
40,  (figs.)  39 

symptoms  consequent   on   non-closure 

or,   124 

BACK,  lying  on,  in  bed,  characteristic 
nightmare  from — what  it  indicates, 
1 80 


Badenweiler,  graduated  walk  at,  for 
Oertel's  treatment,  202_ 

Band  instruments  for  estimating  blood- 
pressure,  71  et  seq. 

Barclay,  Captain,  feat  of  walking  1,000 
miles  in  1,000  hours,  3,  4 

Barnard,   see  Hill   &   Barnard 

Bartel's  tubes  for  drainage  of  legs  or 
scrotum,  204 

Basch,  Von,  sphygmomanometers  of, 
(figs.)  63-5,  67 

Brunton's  modification   of,   65 

— fallacies  in   applying,   68 

— practically  founder  of  blood-pressure 
measurements  in  man,  645 

Basch,  Von,  and  A.  Frohlich,  experi- 
ments of,  on  action  of  cocaine  on 
the  heart — -reflex  mechanism  in  heart 
itself,  part  cause  of  cardiac  pulsa- 
tions deduced  from,  171 

experiments  of,    bearing   out   author's 

view   on   causes  of   tachycardia,  112 

Baths,  as  employed  in  Nauheim  treat- 
ment, 198-9,  (figs.)  197,  199 

— exercises,  general  massage,  as  external 
means  for  increasing  amplitude  of 
pulse,  object  of,  102 

Bayer,  O.,  experiments  of,  on  first  sound 
of  heart,  42 

Beats,    see    heart-beats   and    pulse-beats 

Bed,   getting   into — work  involved  in,    132 

— position    in,    in    regard    to    difficulty    of 

breathing,    133-4 
— in   regard  to   palpitation,    179-80 

— protection    of,    in   tapping,    204 

• — rest  in,   prolonged,   and  absolute 
— best    treatment    in    Graves's    disease, 
184 

severe   cases  of  palpitation,    183 

rules  regarding,    132 

Bed-time,  water  to  be  sipped  at,  by  the 
flatulent,  182 

Beds,  special,  for  patients  with  severe 
valvular  disease,  not  sufficiently  made 
use  of,  134 

Beef-tea,    cardiac   stimulant,    not   nutrient, 

145 
Begbie,   Dr.  Warburton,  and  the  "  Pulvis 

Mirabilis "     for    functional     irritation 

of  the   heart,    181 
Belladonna,    paralysis    of    vagus,    caused 

by — pulse- rate   after,    107 
Belladonna  plaster,  over  heart,  as  cardiac 

sedative,    178 

Bezold,   Von,  see  Traube  &  Von  Bezold 
Bicarbonate   of   soda,    in    sleeplessness   in 

cardiac   disease,    193 
Bidder's     ganglia,     frog's     heart,      (figs.) 

19.  27 

Bigeminal   pulse- -nature — instance,    189 
Bile     acids     in     jaundice,     action     of,     in 

causing  bradycardia,    187 
—elimination       of,       in       toxin  —  caused 

brachycardia,      aim     of     treatment — 

methods  employed,    188 
- — substances   having  poisonous   action    ex- 
creted  in,    reabsorbed   by    liver — risks 

from,     in     angina,     how     eliminated, 

191-2 
Bismuth,  in  treatment  of  bradycardia  due 

to  reflex  inhibition  from  stomach,  188 
— use  of,  in  certain  forms  of  tachycardia, 

185 
Bitartrate    of    potassium,    addition    of,    to 

compound     jalap     powder — advantage 

of,  203 
Bladder,    see    Urinary    bladder    and    Gall 

bladder 


INDEX 


237 


Blake,  demonstration  by,  of  action  of 
digitalis,  146 

Bleeding — general,  from  the  arm — cases 
in  which  beneficial,  175,  208 

to   slow  very   rapid  pulse,    166 

—local,  by  leeches  and  cupping — cases  in 
which  beneficial — action  not  under- 
stood, 177 

Blocking  of  the  coronary  arteries,  conse- 
quences of,  96,  100,  105-6 

Blood,  bulls',  drinking  warm  as  punish- 
ment, 141,  and  note 

— circulation  (q.  t'.)  of,  how  kept  up  by 
the  heart,  96-8,  and  figs. 

• — diluted,  as  used  in  Ludwig's  artificial 
circulation  experiments,  143 

— driven  back  into  auricle  and  pulmo- 
nary veins  in  mitral  incompetence, 
127 

— flow  of  (see  also  Circulation),  during 
syncope — Hunter's  observation  on, 

US 
— quality    of,    effect    of   alteration    in,    100 

effect  of,   on  nutrition  of  heart,   94 

— quantity  of,  in  the  body,  Ludwig  cited 
on,  5 

effect  of,  on  nutrition  of  heart,  94 

— from  stomach,  passage  of,  through  liver 
before    reaching    general    circulation 
— why  to  be  remembered  in   relation 
to  palpitation,    (fig.)    179 
— well  aerated,  best  cardiac  nutrient,   143 
Blood    and   lymph,    circulation   of,    as   af- 
fected by 

self-massage  of  heart  and  arteries,  6, 

7.   8,  97-9,    102 

as   affected   by   digitalis,    153 

as  affected  by  massage,  138,  and  ex- 
ercises, 202 

Blood-pressure,  see  also   arterial   tension 
— abnormally  low,   as  precursor   of  phthi- 
sis— case   in   point,    105 
— in   animals,   60 
— backward      (see      also      Regurgitation), 

causes — consequences,    128-9 
— in   brain,   in  relation   to   position,    114 
— in  the  capillaries,   measurement  of,   84, 

(jtg.)   62 

- — Cause    of,    on   what   dependent,    13-14 
— in    dog's    heart,    slow    fall    after    high 
rise — how     caused — Brunton,     Meyer 
and    Tunnicliffe's    experiments,     158, 
(figs.)    157-8..    . 
— effect    on,    of    injection    of    adrenaline, 

160 

— enormous,    caused    by    nicotine — a    par- 
allel— the    reason,    167 
— in    gouty    kidney    disease,    difficulty    in 

reducing,    101 
— high,    in    advanced    age,    treatment    of, 

208-9. 
— in  auricle,  pulmonary  veins,   and  aorta, 

in  mitral  incompetence,   127 
— in    auricle    and   ventricle    in    mitral    ob- 
struction,   127-8 

extra  work  of  the  heart  in  overcom- 
ing —  causes  —  bradycardia  caused 
by,  1 88 

• risks  of,   in  combination  with  athero- 

matous    arteries,    206-7 
— increase  of,  as  found  in  diffuse  arterio- 
sclerosis, dangers  from,    101 
— influence  on,   of  splanchnic  area,    16 

of  vagus  nerve,    15,    (fig.)    13 

of  yaso-motor   center,    15,    (fig.)    13 

— lowering  of,  caused  by  amyl  nitrite — 
Gamgee's  &  Brunton's  experiments 
in  full,  163 


Blood-pressure    in    man,    60 

measurement  of,  author's    experiments 

with    different — by    finger   pressure, 
60,    instruments — deductions,    79 

instruments  for    (see   Cardiographs, 

Haemodynamometer,  Kymographs, 
Manometers,  Plethysmographs, 
Sphygmographs,  and  Sphygmo- 
manometer),  described,  10-12, 
55,  60  et  seq.,  90 
— standardization  of,  author's 

method,  82 

— two  classes  of,  (a)  for  com- 
pressing single  artery,  62  et 
seq.;  (b)  for  compression  of 
digit  or  limb,  ib. 

— maximum,     coincidence    with,     of    stop- 
page  of   urine    secretion,    in   cases   of 
poisoning     with     digitalis    and     stro- 
phanthus,    observed    by    Brunton    and 
Power  and   Brunton  and  Pye,  155,  156 
— measurement     of,     in     relation     to     pro- 
longation of  life,  205,   209 
— rapid   raising  of    (however  caused),    an- 
gina   pectoris   brought   on   by,    (figs.) 
190,    189 

— diet   in  connection  with,    191-2 
- — regulation   of,    13 
— rise  of,  in  chronic  interstitial  nephritis, 

risks   from,    to   life,    49-51 
due  to  digitalis,   as  affecting  the  kid- 
neys, 51 

cause  of,  according  to  Traube  and 

Von  Bezold,  157,  views  of  Brun- 
ton - — •  experiments  of  Brunton 
and  Meyer,  157-8,  and  of  Brun- 
ton and  Tunnicliffe  confirming, 
158 

risks  of,   163,  how  overcome,    163 

— sources  of  mischief  in,    14 
— in   the   veins,   measurement   of,    83-4 
Blood-supply,     of    arm     at     bend — source 
of — author's    deduction    from,     as    to 
syncope,    115 
— to    brain,     insufficiency    of — as    causing 

syncope,   15,    (fig.)    12,    114 
— to    heart,     importance    of    quality    and 
quantity  of,   and  why,   94-5,  98-9 

function    of    the    coronary    arteries 

in,   95-6 

enlarged  by  aortic  regurgitation,  more 

required — consequences    if    not    de- 
livered,   123 
- — large,    required    by    brain    when    active, 

114 
— quantity    of,    in    heart — how    increased 

by  digitalis,    149 

Blood-vessels,  see   also  Arteries  and  Veins 
— action    on,    of   adrenaline,    160 
— alone     chiefly     acted     on     by     Erythro- 

phlceum,    160 
— alteration     in,     the     primary     cause     of 

senile   decay,    207 
— as   well    a_s   heart   acted   on   by   digitalis, 

1 60 
— Cerebral     diseases    of,     in     relation    to 

senile  decay,   206 

— contraction    of,    by    application    of   cold 
• — relieving  inflammation,    175 

caused    by    digitalis,    etc.,    drawbacks 

incidental  to,  162,  overcome  by 
combination  on  the  vaso-dilators, 
163 

injection   of  adrenaline,    160 

rhythmical,    discovered    by    Wharton, 

Jones  and  others,  46— cause, 
according  to  Luchsinger  and 


THERAPEUTICS    OF   THE    CIRCULATION 


Schiff — observations    on,    by    au- 
thor and   Fayrer,    27 

Blood-vessels,  contraction  of,  reflex  of, 
not  present  in  reflex  stoppage  of 
heart  in  imperfect  anaesthesia — au- 
thor's view,  113-4 

— dilatation  of,  to  relieve  the  heart,  in 
attacks  of  angina  pectoris — methods 
of,  189,  191,  192 

— diseases  of,  frequency  of  deaths  from, 
in  old  people,  206 

— effect  on,  of  heat  and  cold,   51-4,   106 

local,    as   affecting    local    inflamma- 
tion,   174-5 

x of  shock,    113 

— enfeeblement  of,  fourth  stage  of  action 
of  digitalis,  160 

— excessive  tension  in,  effect  of,  on  the 
vagus  center,  15,  (fig.)  13 

— exudation  of  fluid  from,  cause  of 
oedema,  how  arrested  by  digitalis,  153 

— nutrition  of,  effect  on,  of  feebleness 
of  the  heart,  100 

— obliteration  of,  caused  by  embolism 
and  thrombosis — gangrene  ensuing, 
115-6 

— opposing  action  of  nerves  in,  45 

— ossification    of,    consequences,    1 16-7 

— power  of,  to  contract  or  dilate  from 
alteration  in  contractile  apart  from 
nervous  element,  47 

— rupture  of,  in  brain— how  caused,  205; 
results.  206 

risk    of,    from    arterio-capillary    fibro- 

sis,    101 

— stimulation   of,    from   within,   49-51 
— from  without,   47,   49,    (figs.)    47.    48 

— tonic  effect  on,  of  digitalis — "roved  by 
author,  146,  and  note 

— vessels  of  the  heart,  effect  on,  of  heat 
and  cold,  106-7 

— vessels  of  Thebesius,  circulation  some- 
times maintained  by,  in  default  of 
coronary  arteries,  96 

Blow  on  abdomen,  twofold  action — shock 
induced  by  —  Goltz's  experiment  on 
frog  showing,  1 13 

Blue  pill,  powdered  digitalis  and  pow- 
dered squill — pill  of — value  of,  modi- 
fications of,  203 

Bokenham,  Mr.  T.  J.,  see  Brunton  and 
Bokenham 

Bowditch's  (Dr.  H.  P.)  apparatus  for 
experiment  on  frog's  heart,  (fig.  and 
note)  22 

Bowels,   as  affected  by  compassion,    104 

— attention  needed  by,  in  relief  of  palpi- 
tation— why,  181 

—to  be  kept  freely  open  in  angina  pec- 
toris— how — why,  191 

• — treatment  of,  in  senile  rise  of  pres- 
sure, 208 

Brachycardia,  see  also  Bradycardia 

Bradycardia  —  chief  characteristic,  slow 
pulse,  108,  186 

— causes,    108-9,    186-7. 

— when  most  frequent,   186-8 

— treatment  of — aims  in,   188 

— pulse  in,  rate  altered,  rhythm  regular 
— varieties  of  intermission  in,  109-12 

Brain,  see  also  Medulla 

— arteries  of,  as  affected  by  Raynaud's 
disease,  117 

• — blood-pressure  in,  as  affected  by  posi- 
tion, 115 

— blood-supply  to,  defective — causes  and 
consequences,  123 


Brain,  large  supply  of  blood  required  by, 

when   active,    114 

• — condition  of,   in   shock   (clear),    114 
— in   syncope    (unconscious),    114 

— due  to  inadequate  blood-supply,  15, 

(fig-)  12 
— nerve  cells  in,  destroyed  by  macrophags 

in  old  age,   207 — reason,   207 
— pressure   on,    various   forms   of    causing 

bradycardia,   109 
— rupture    of    vessel    in,    in    old    people, 

cause  of,    205 — results,    205 
— stimulation  of,  by  tobacco-smoking,    169 
— sudden    anaemia    of,    probable    cause    of 

syncope,    114,   and  see    15 
Braune,    cited    on    walls    of    veins    when 

stretched,  6 
Bread,   made  with   sugar  and   no   salt,   in 

diet    for   mitral    disease — aim   of,    204 
Bread    and    tea — fatal    meal    of — why    so, 

140-1 
Breath,     shortness    of     (see    also    cardiac 

dyspnoea),    in    mitral    incompetence — 

treatment,    197 
Breathing,     difficulty    of,    in    recumbency, 

133 — probable  twofold   origin   of,    133 
Bright's    disease,     advanced,     double    risk 

in,  of  use  of  digitalis,   163 
— arterial    distention    due    to    tracings    of 

aortic     pulse     consequent     on,     89-90, 

(fig.)  88 

— bradycardia  caused  by,    109 
Brodie,    Sir   Benjamin,    cited   on   claudica- 

tion  before  senile  gangrene,   116,  and 

on    angina   pectoris,    it>. 
Bromide  (s)     of    potassium,     in    treatment 

of   bradycardia   due   to    reflex   inhibi- 
tion from  stomach,   188 
—sodium    and    ammonium,    separately    or 

mixed,    in    treatment   of    sleeplessness 

in  cardiac   disease — doses,    193 
— use    of,    in    certain    forms    of   tachycar- 
dia,  185 
— useful   in   Graves's   disease — why — how, 

184 
Bronchitis,    chronic,    strain    due   to — effect 

of,   on   right   side   of   heart,    130 
• — suffocative,   wet   cupping  over   the   back 

for,   177 
Bronchitis  and  emphysema,   results  of,  to 

the  heart,  202 
Brucke's  analogy  for  the  pericardium,  and 

view   of   suction-action   of  ventricular 

systole,  97,    (fig.)   96 
Bruits  or  murmur — cardiac,  characteristic 

sounds  of,   how  caused,  43 
Brunton,    Lauder — 

- — advice    and    rules   of,    on    rest    for    pa- 
tients,   132 

— arrangement   of   for   evacuation    for   pa- 
tients kept   recumbent,    132-3 
— diagrams    by,    of    hypothetical    nervous 

apparatus,     frog's     heart,     (fig.     and 

note)   20 
to  illustrate  the  experiments  of  Stan- 

nius,  20 
— discovery  by,   of  action  of  amyl  nitrite, 


165 
— double 


ile  action  of   digitalis  and   its  tonic 
effect    on    heart    and    vessels    proved 
by,    146,  and  note 
— experiments  of,  on 

action   of   digitalis,    162-3 

• — regurgitant     murmur     observed     in 

healthy    heart    of    dog    poisoned 
with,   126 
thirst  produced  by,   150,   152 


INDEX 


239 


Brunton,  experiments  of,  on  action  of 
blood-pressure  in  man  as  ascertained 
by  different  instruments — deductions, 
79 

effects  of  heat  and  cold  on  frog's 

lungs,  56,  (fig.)  54 

own   pulse,    130,    163 

— importance  of  arterioles  pointed  out  by, 

.    J57 

—instruments  or  apparatus  devised  or 
adapted  by,  for  various  purposes, 

ascertaining   competence  of  mitral   or 

tricuspid   valves,    etc.,    (fig.)    38 

combination    of    Ludwig's    and    Pick's 

kymographs,    (fig.)    59 
— combination     of     Potain's     sphygmo- 
manometer  with   other  instruments, 
(fig.)    80 

modification  and   application  of  Riva- 

Rocci's    sphygmomanometer,     (figs.) 
79,   80 

modification  of  Von  Basch's  sphyg- 
momanometer, 63,  further  modifi- 
cation, (fig.)  80 

showing  action  of  heat,  cold,  and  poi- 
sons  on    frog's   heart,    (fig.)    21 
— showing  effect  of  heat,  cold,   and  poi- 
sons on   frog's   lungs,    56,    (fig.)    54 
standardizing     an     aneroid     sphygmo- 
manometer,  82,    (fig.)    83 
— observations  of,  on 

— action  of  nitrite  of  amyl  in  angina 
pectoris — tension  reducing  power 
proved  by,  163 

angio-neurotic   oedema,    118 

— arterial  tension  and  quick  pulse  in 
relation  to  pain  of  angina  pectoris, 
121,  and  note 

case    of    cardiac    strain    from    indoor 

dancing,   126 

— dilatation    of    arterioles    sometimes 
due   to   local   irritation,   46 

distensibility  of  liver,   17 

effect  of  ammonia  liniment  over  car- 
diac region,  178 

nicotine    in    raising    blood-pressure, 

167 

smoking   "  pig-tail  "   tobacco,    170 

fingers  in  Raynaud's  disease,   117 

his  own  sensation  of  chest-oppression 

due   to    grief — deductions,    121 
influence  of  oxygen  in  relief  of  car- 
diac asthma,   193 

irregularity    of    pulse    from    digitalis 

poisoning,    no-n,    (figs.)    in 

local  irritation   as  sometimes  causing 

dilatation,    and    not    contraction    of 
arteriole,   46 
— migraine — own  case,    119-20 

mitral     regurgitation     from     digitalis 

poisoning  in  a  dog,    126 
— as  affected  by  exercise   and  excite- 
ment,   126 

one-sided      case      of      angio-neurotic 

oedema,    118 

only    ill-effects    of    amyl    nitrite,    or 

nitro-glycerine,    191 
— — peristaltic    action   of   arteries,    5 
—pattern    of    belladonna    plaster    advised 

by,   178 
- — schema  of   the  circulation  by,  57-9,  (fig.) 

— use  by,  of  amyl  nitrite  for  first  time 
in  angina  pectoris,  175,  177 

of  bleeding,    175,    177 

of    calcium    chloride    and    suprarenal 

extract,    in    Graves's    disease,    183-4 


Brunton,    Lauder,   views  of,   on 
— albumen   in   urine,   not   contra-indica- 
tion  of  use  of  opium  or  morphine, 
195 

arterial    contraction     as    largely    the 

cause  of  high  tension,  50 

cause  (s)     of     emptiness     of     arteries 

after  death,   5 

intermittent  pulse,   109-12 

senile  decay,   207 

effects  of  imperfect   anaesthesia,  113-4 

— on  palpitation  and  its  causes,   112 

transverse     as  kwell    as    longitudinal 

contraction    in    muscular    cells    of 
arterioles — effect  of,   45 

treatment    of    bradycardia,     188,    and 

note 

— work  of,  on  action  of  drugs  on  blood- 
pressure — when  begun,  1 1 

Brunton  and  Bokenham,  experiments  of, 
on  action  of  hydroxylamine,  166 

Brunton  and  Cash,  experiments  ,  of,  on 
the  action  of  strychnine  on  the  heart 
— deductions,  161,  and  note 

on  nervous  and   muscular  conduction 

in    the    heart,    33,     (figs.)     35 — de- 
ductions, 34  et  seq.,  36 

on    oxidation    of    protoplasm    acceler- 
ated  by    digitalis   and   caffeine,    148 

Brunton  and  Fayrer,  rediscovery  by,  of 
independent  pulsation  of  veins,  18, 
44,  127-8,  note 

Brunton  and  Gamgee,  experiments  of,  on 
the  former  in  nitrite  of  amyl,  163-4 

Brunton  and  Gresswell,  experiments  of, 
on  the  action  of  other  nitrites — un- 
published, 1 66 

Brunton  and  Meyer,  experiments  by, 
proving  importance  of  arterioles, 
157-8,  and  figs.  156,  157 

Brunton  and  Power,  observations  of,  on 
coincident  arrest  of  secretion  of 
urine,  in  digitalis  poisoning,  with 
maximum  blood-pressure,  155-6,  and 
on  condition  of  urine  subsequently, 
156 

Brunton  and  Pye,  observations  of,  on 
coincident  arrest  of  secretion  of 
urine  in  strophanthus  poisoning,  with 
maximum  blood-pressure,  and  on  sub- 
sequent condition  of  urine,  155-6 

Brunton  and  Tait,  experiments  of,  on 
nitroglycerine,  165 

Brunton  and  Tunnicliffe,  experiments  of, 
on  effect  of  digitalis  during  irrita- 
tion of  vagus,  158 

Buisson,  instrument  of,  for  estimating 
blood-pressure  in  a  limb,  71 

Bull's  blood,  warm  draughts  of,  as  pun- 
ishment— effect  of,  141,  and  note 

Burdon-Sanderson,  Sir  John,  see  Sander- 
son, Sir  John  Burdon- 

CABBAGE,    to    be    avoided    in   palpitation — 

why,   181 

Caffeine   or   trimethylxanthine, 
— action  and  use  of,  as  cardiac  tonic,  98, 

145,   161-2,  203 

in  large  and  small  doses,    145 

on  the  heart  of   embryo   and   adult — 

Pickering    on,    148 
Caffeine    and    strychnine,    in    combination 

with   digitalis,    benefits  of,    in    certain 

cases    of    aortic    regurgitation,     with 

care,    196-7 
Calcium     chloride,     used     by     author     in 

Graves's  disease,   184 


240 


THERAPEUTICS    OF    THE    CIRCULATION 


Calcium  and  its  salts,   diminished   transu- 

datioii    effected    by — deduction    as    to 

diet,  204 
Calomel,  in  treatment  of  cardiac  diseases, 

203 
Canadian    hemp  (Apocynum  cannabinum), 

medicinal   uses   of,    146 
Cancer,    reflex    irritation    from — bradycar- 

dia  due  to,    109,    187 
Capillary  (ies),    contractile    cells    and    no 

muscular  layer  in,  45 
— contractility  of,   established  by   Strieker 

and  others,  46 
— dilatation,    as    affecting    sphygmograms, 

90,    (figs.)   88,  89 
— in   frog's  foot,    dilatation   of  by   nitrite 

of  amyl    (Richardson),   163 
— measurement  of,  pressure  in,  84,    (fig.) 

62 
— pulmonary,  effect  on,  of  heat  and  cold, 

Si,  (fig-)  54 

giving     way     of,     cause     and     conse- 
quence,   129 

— rhythm,   the,   47 

Capillaries  and   arteries,   45 

— blood  entering  and  leaving,  need  of 
balance  between — results  of  upset- 
ting, 13-15 

Capillaries  and  small '  arterioles,  diseases 
in  which  chiefly  affected,  117-8 

Capillaries  and  veins,   5 

Cardiac  action,  effect  on, 

of  chloral,   193 

of  fatty  degeneration,   105 

of  nicotine,   described  and  explained, 

167-8 

Cardiac  asthma,  causes — symptoms — treat- 
ment, 1 92-3 

Cardiac  beat  (see  also  Heart-beat),  origi- 
nating frequently  in  independent  pul- 
sations of  vena  cava  and  pulmonary 
veins,  18,  44 

Cardiac  depressants,  see  infra,  drugs 
used  in  cardiac  diseases 

Cardiac  diseases  (see  tinder  name  of  each 
form) 

— commonest,  connected  with  faulty 
valves,  40 

— deaths  from — statistics  of,  in  old  peo- 
ple, 206 

— diet  advised  in,  by  Schott,   201 

— drugs,  etc.,  used  in,  classes  of,  i/ii,  143 

(i)    cardiac  nutrients,    141,    143 

blood,  well  aerated,  the  best,   143 

glucose,    145 

— saline    solutions,    141,    145,    (figs.) 
144  _ 

(2)    cardiac  tonics,    141 

- — — — action  of,   on  embryonic  heart — -re- 
lation  of,    to    oxidation,    147-8 
— digitalis  (q.  v.)  proved  to  be  so  by 

author,    146,   and   note 
— and   its   congeners,    145-7 — draw- 
backs  to    action  of,  162-3 — how 
removable,    163 
— nutritive  effects  of,   98 

other   than   digitalis,    difference  be- 
tween them  and  it,    160 

(3)    cardiac  stimulants,    141,    145 

adrenaline,    160 

— beef-tea   and  meat-extracts,    145 

caffeine,    145,   161-2,   203 

purin   bodies,    145,    161-2 

(4)   cardiac  depressants,    141 

aconite,     171 

chloral,    193 

digitalis  formerly  regarded  as,    146 

(5)    vascular   contractors,  1 141 


Cardiac    diseases,  drugs    used  in,  continued 
(6)   vascular  dilators,   141,   163-6 

(7)    others    with    indirect    action    on 

heart,   143 

— forms  of,  most  liable  to  sudden  death, 
196 

— sleeplessness      frequent      along      with — 
characteristics — aggravations — treat- 
ment, 193  et  seq. 

• — surgical  treatment  of,  possible  benefit 
in  some  cases,  205,  and  note 

• — treatment  of  (and  see  under  name  of 
each  form),  178  et  seq. 

surgical,   205,   and  note 

ultimate    impotence,    some    cases,    205 

— unenumerated   forms  of,    129-30 

— use  of  drugs  in,  141  et  seq. 

— use  in,   of  purgatives,  203 

mercurial     purgatives,     value    of — 

author's  view,   208 

— vicious  circle   in,    131 

Cardiac  dyspnoea,  associated  with  mitral 
obstruction  and  regurgitation,  128-9 

Cardiac  failure,  causes  and  symptoms  of, 
126 

— common  cause  of  death  in  old  age,  pos- 
sibility of  averting,  by  treatment  of 
arterial  conditions,  209 

— danger  of,  in  condition  of  high  blood- 
pressure  combined  with  atheroma  of 
arteries,  205 

— threatened  by  rise  of  blood-pressure  in 
chronic  interstitial  nephritis,  49 

Cardiac  ganglia  (see  also  Ganglion-cells), 
importance  of,  32,  and  note 

Cardiac  movements,  slowing  of,  when 
requisite — two  modes  of  effecting,  15, 
and  note,  (fig.)  13 

— views  on,  of  Gaskell  and  of  Engel- 
mann,  18-19 

Cardiac  murmurs,  see  also  Sounds  of 
heart 

carotid  pulse  to  be  used  to   fix  time 
of,    when — and    why,    92 

characteristic  sounds  of,  to  what  due, 

43 
Cardiac    muscle,    effect    on,    of    digitalis, 

147-8 

— fatty  degeneration  of,  see  that  head 
— local   action   on    (probable '.    of  aconite, 

171 

— nerve-like  action  of   (Gaskell),  25 
— want  of  relationship   between   its  power 
and  the  resistance  to  be  overcome  by 
it — the  probable  cause  of  angina  pec- 
toris,    189 
- — weakness  of,  indicated  by  lessened  first 

heart  sound,   42 

Cardiac  nerves,  abundance  of— functions, 
32  et  seq. 

intrinsic,    effect   on,   of   digitalis,    147 

— opposing  action  of,  45 

probable  importance  of,  32,  and  note 

Cardiac  nutrients,   see  under  cardiac  dis- 
eases,   drugs,    etc.,   used   in,   supra 
Cardiac  nutrition,   how  benefited  by  digi- 
talis,  149  et  seq. 

by  Nauheim  treatment,  201 

— how  effected,  importance  of,  94,  and  of 

its  own  activity,  98 
— self-massage  in   relation   to,    96-98 
— tonics    (cardiac),   how  they  aid,  98 
Cardiac    pain    (see   also   angina   pectoris), 
caused   by   over-smoking,    170 

self-caused,    121 

Cardiac  plexus,  vagus  branches  in,  pos- 
sible effects  of  irritation  of,  in  caus- 
ing bradycardia,  186 


INDEX 


241 


Cardiac  pulsations,  reflex  mechanism  con- 
cerned with,   how   deduced,    171 
Cardiac    region,    local    applications    over, 
pressure,     heat,     and     cold,     benefits 
from,    177-8 

Cardiac  rhythm,    disturbance  of, 
— by  mitral  obstruction,   128 
— by  mitral  regurgitation,    12? 

— consequence  in  both  cases,   128,  129 
— nervous     system's     share     in,     author's 
view   on,   as  possible   cause  of  tachy- 
cardia,   I  12 

Cardiac  sedatives,  local  and  external,   178 
Cardiac  stimulants,  see  under  cardiac  dis- 
eases,   drugs,   etc.,    used   in,   supra 
Cardiac  strain,   dilatation  due  to,    126 
— induced    by    excessive    exercise — symp- 
toms— treatment,    184 

Cardiac    tonics,    see    under    cardiac    dis- 
eases, drugs,   etc.,  used  in,   supra 
Cardiac  uneasiness,   causes,    123 
• — frequently  felt  without  pain,    120-1 
Cardiac  walls,  disease  or  degeneration  of, 
causing 

(a)  paroxysmal  tachycardia,    108 

(b)  bradycardia,   108 
Cardiac  weakness, 

after   diphtheria,    double   cause,    105 

bradycardia   due  to,    108,    186-7 

causes — - 

— fatty  degeneration,    100,    105 
nervous  depression,   103,   104 

dilatation  of  the  heart  due  to,   126 

effect    on,    of    digitalis,     former, 

and    present    (true)    view    of, 
146,  and  note 

— effect  of,   on  nutrition  of  blood- 
vessels,   1 02 
— sphygmograms  of,   90,    (figs.)    88,   89 

Cardiograph  and  sphygmograph  (q.  v.), 
Burdon-Sanderson's,  for  apex-beat, 
84,  (figs.)  86 

— Marey's,  86,  investigations  with,  86-90, 
(figs.)  88,  89 

Carminatives,  alone,  or  with  rhubarb,  in 
treatment  of  sleeplessness  in  cardiac 
disease,  193 

— benefit  from,  in  attacks  of  angina  pec- 
toris,  189 

— for  relief  of  palpitation,  due  to  flatu- 
lence— two  prescriptions,  180 

Carotid  artery,  alterations  observed  in,  in 
migraine,  119-20 

• pressure   on,    relieving   migraine,   why 

of  little  use,   120 

Carotid  pulse,  to  be  used  to  fix  time  of 
cardiac  murmurs — when  and  why,  92 

Casca  or  sassy-bark  (Erythrophlocitm 
guinense),  medicinal  uses  of,  146,  160 

Cascara,  as  aperient,  in  cases  of  senile 
high  pressure,  208 

Cash,  Dr.  (see  also  Brunton  and  Cash), 
instrument  devised  by,  for  experi- 
ments on  frog's  heart,  34,  and  note 

Cash  and  Dunstan,  research  by,  on  var- 
ious nitrites — results,  166 

Cerebral  abscess,  bradycardia  in  conjunc- 
tion with,  187 

— apoplexy  in  advanced  years,  cause  of, 
205 — possible  means  of  averting,  209 

• — vessels,  diseases  of,  in  relation  to  se- 
nile decay,  206,  207 

Cervical  cord,  disease  of,  or  injuries  to, 
bradycardia  due  to,  109,  188 

Cetti,  Mr.,  modification  of  Von  Basch's 
sphygmomanometer  made  by,  to  au- 
thor's plan,  65 

'7 


Chair  for  sitting  patients  with  severe  val- 
vular disease,  133-4 

Chelius's  instrument  for  estimating  blood- 
pressure,  78 

Chest,  oppression  of,  caused  by  irritation 
of,  or  pressure  on,  the  vagus — cases 
illustrating,  120-1,  and  note 

Chewing  tobacco,  nicotine  absorption  in, 
168 

Chilblains,   causes   of,    117 

Child-birth,    slowness  of  pulse  after,    186 

Chloral,  in  treatment  of  sleeplessness  in 
cardiac  disease — dose — action  of,  193 

Chloride-free  food,  milk  and,   204 

Chlorides,  effect  of,  on  transudation  from 
vessels  into  tissues — disadvantageous 
in  dropsy,  204 

Chloroform,  effect  of,  on  medusae  (con- 
tractile tissue),  30 

— fatty  degeneration  of  the  heart,  found 
after  administration  of,  ipo 

— few  whiffs  of,  to  assist  action  of  nar- 
cotic in  sleeplessness  in  cardiac  dis- 
ease, 195 

- — reinforcing  of  morphine  in  relief  of 
neuralgic  element  in  angina  attacks 
- — how  given,  191 

Chlorosis,  bradycardia  associated  with,  186 

Chocolate,  dietetic  action  of,   162 

Cholera  toxins,  effect  of,  on  stomach,    155 

Christmas  rose  (Helleborus  niger),  uses 
of,  146 

Chronic  alcoholism,  fatty  degeneration  of 
heart,  in,  100 

— bronchitis,  strain  due  to — effect  of,  on 
right  side  of  heart,  130 

— contraction  of  arterioles — causes — con- 
sequences, 50 

— dyspepsia,  bradycardia  caused  by — how, 
109 

— inflammation  of  the  brain,  bradycardia 
caused  by — how,  109 

— interstitial  nephritis,  bradycardia  in- 
duced by — how,  1 88 

— myocarditis,  diet  in,  according  to 
Schott,  20 1 

— pharyngitis,  and  its  concomitants  due 
to  excessive  smoking,  170 

Cigar-smoking,  why  less  harmful  than 
cigarette-smoking,  169 

Cigarette-smoking,  chief  dangers  of,    169 

Cinders,  and  modified  products  of  tissues 
— parallel,  143,  145 

Circulation  of  the  blood,  see  also  entero- 
hepatic  circulation  and  pulmonary 
circulation 

— accessory   muscles  of,    6 

— aid  to,  from  the  fasciae,  6,   131 

— artificial,  Ludwig's  methods  for  secur- 
ing, 143,  (fig.)  142 

• — branches  of  science  involved  in  treat- 
ment of,  i 

— in   coronary   arteries,   see   that   head 

— disordered — action  of,  on  other  or- 
gans, and  their  reaction  worsening  it 
— how,  131 

— disturbance  in,  from  sleeping  on  the 
back — how  deduced,  180 

• — effects  on,  of  digitalis — first  stage,   159 

of  heat  and  cold,   51,    (figs.)    50,    52, 

53 

of   mercury,   in   albuminuria,    208 

of  over-smoking,    170-1 

— in  fevers — rapidity  of — reason   for,    107 
—general,   abnormally   high   pressure   in — 
cause — bradycardia  caused  by,    188 


242 


THERAPEUTICS    OF    THE    CIRCULATION 


Circulation  of  the  blood,  general,  more 
affected  by  nitrites  than  pulmonary 
circulation,  193 

— how  maintained,   96,   and  figs.,   113 

— imperfect,  waste  products  due  to — elim- 
ination of,  20 1 

— local  modification  of — in  inflammation 
— methods  of,  explained,  174-5 

— mammalian,  experiments  on,  of  Traube 
in  relation  to  digitalis),  146 

— pathology  of,    i 

effect  of  altered  quality  of  blood,   100 

— blocking     of     coronary     arteries — 

consequences,   96,    100,    105 
— feebleness   of   the    heart    on    nutri- 
tion of  blood-vessels,    102 

exophthalmic   goitre,    107 

fatty  degeneration,    105-6 

nervous    depression,    102,     104 

pulse-rate,    106-7 

— pharmacology  of,    i 

- — quieted  in  nervous  fluttering  of  heart 
by  very  small  doses  of  aconite,  172 

— schema  of   (author's),   57,    59,    (fig.)    55 

— semeiology  of,   2 

— therapeutics  of,  2  et  passim. 

— venous,  how  benefited  by  digitalis,  149- 
50 

how   maintained,   subsidiary   agencies, 

5-6 

— of  blood  and  lymph,  9,  10;  as  affected 
by  self-massage  of  heart,  96-8,  (figs.) 
97,  and  of  arteries,  99,  101,  (figs.) 
6,  99,  134 

Circulatory  nerves  and  muscles,  increased 
action  of  all,  first  stage  of  action  of 
digitalis,  159 

Clark,  Sir  Andrew  (the  late),  failure  of 
to  diagnose  aortic  regurgitation — how 
caused,  195-6 

Claudication,  Brodie's  description  cited, 
116 

Coagulation  in  using  kymographs,  how 
prevented,  59 

Cocaine,  action  of,  on  the  heart,  experi- 
ments in,  of  Von  Basch  and  A. 
Frolich,  deductions  from,  as  to  exist- 
ence in  the  heart  of  sensory  mech- 
anism, part  cause  of  cardiac  pulsa- 
tion, 70 

Coeliac,  hepatic  and  splenic  plexuses,  ac- 
tion of  the  pneumogastric  nerve 
through,  on  intestines,  liver,  and 
kidneys,  104,  note 

Coffee,  to  be  avoided  in  angina  pectoris 
_ — why,  191 

— dietetic  action,  162;  medicinal  action  of 
derivatives,  162 

— excessive  use  of,  as  cause  of  palpita- 
tion— to  be  cut  off,  or  docked,  179 

— poison  in,  bradycardia  caused  by,  109, 
187 

— strong,  to  relieve  paroxysmal  tachy- 
cardia, 184 

Cohnheim,    see    Gunning    and    Cohnheim 

Colchicum,  to   show  very  rapid   pulse,    166 

Cold,  see  heat  and  cold 

— bandage  covered  with  oil-silk,  effects 
of,  how  evidenced,  175 

— external,  locally  applied,  sedative  effect 
of,  on  heart,  178 

— external  and  internal,  in  paroxysmal 
tachycardia,  uses  of,  184 

— local  application  of — effect  of,  on  an 
artery,  175,  (fig.)  176 

— modification  by,  of  local  circulation  in 
inflammation  —  when  of  use  —  why, 
'74-5 


Cold-water  compress,  uses  of,   175 

Colds,  see   febrile  colds 
Colic,   pain    of — how   caused — that    of   mi- 
graine  similar  to,    120 

Colin,  acquainted  with  the  independent 
pulsation  of  veins  (1862),  18 

Collapse  after  slowing  of  pulse  and  ex- 
cessive vomiting,  caused  by  toxic 
doses  of  digitalis,  155 

Collidine  in  smoking-tobacco  in  its  var- 
ious forms,  1 68 

Compassion  as  affecting  the  bowels,    104 

Compensation,    see   failing   compensation 

Compensatory  hypertrophy  of  the  ven- 
tricle, when  occurring,  123 

Compound  jalap  powder,  in  treatment  of 
cardiac  diseases — use — dose,  203,  how 
enhanced  in  effect,  203 

Compression,  a  s  affecting  passage  of 
stimuli  in  medusae,  29,  and  frog's 
heart,  31 

Conduction  of  stimuli  (see  also  Trans- 
mission) in  the  heart,  nervous  and 
muscular,  experiments  of  Brunton 
and  Cash,  32,  33,  and  note,  (figs.) 
35;  deductions,  34,  35 

Congestion  of  liver,  etc.,  lessened  by  mas- 
sage, 138 

Contractile  effects  of  digitalis  on  frog's 
heart — not  overcome  by  atropine,  148 

— force  of  arteries,  to  what  due,  work 
done  by,  10 

— muscular  walls  and  accompanying 
nerves  of  arterioles,  effect  on,  of  dig- 
italis, 147 

— power  of  the  aorta,   44 

blood-vessels,   apart  from  influence  of 

nervous   system,    46 
— heart,  dependent  on  due  nutrition,  94 

— tissue  of  medusae,  action  on,  of  poi- 
sons (Romanes),  29,  30,  (figs.)  28, 
30,  31 

Contractility  of  arterioles,  probable  effect 
of,  ip 

— of  capillaries,  established  by  Strieker 
and  others,  46 

— in  protoplasm,  under  stimuli,  (a)  un- 
differentiated,  24,  25;  (b)  differen- 
tiated, 25 

Contraction  of  abdominal  vessels,  caused 
by  severe  pain,  circulation  main- 
tained by,  113 

— of  arterial  walls  with  degeneration  in 
the  old — senile  gangrene  due  to,  116 

— arteries,  caused  by  local  application  of 
cold,  175,  (fig.)  176 

peripheral,    with    central    dilatation — 

cause  of  migraine  in  author's  view, 
1 20 

temporary,    in     Raynaud's     disease — 

consequences,   ordinary,    and  in   se- 
vere cases,   117 

tendency   to    rhythmical,    in   cases   of 

aortic    regurgitation,    123 

— of  arterioles,   caused  by  digitalis,    147 

by  nicotine,  method  of,   167 

— chronic,  of  arterioles — causes,  conse- 
quences, 50 

— of  the  heart,  mode  of,  instruments  for 
ascertaining,  84  et  seq. 

— of  isolated  frog's  heart,  effected  by  dig- 
italis, 147-8 

• — muscular,  as  affecting  flow  of  blood,  6, 
and  lypmh,  9,  (figs.)  7,  8 

— of  muscular  fibers,  in  (i)  heart,  (2) 
arteries,  in  mammals,  caused  by  dig- 
italis —  how  effected  —  consequences, 
149  et  seq. 


INDEX 


243 


Contraction    of    abdominal   vessels,    rapid- 
ity   of,     cause     of    loud     first    heart 
sound — how  it  acts,  43 
— reflex,   of  vessels,  not  present  in  reflex 
stoppage    of    the    heart    in    imperfect 
anaesthesia — author's  view,    113-4 
— rhythmical,   of   arteries,   tendency  to,  in 

aortic  regurgitation,    123 
—of    vessels,     caused     by     application     of 
cold — effect   of,    on   inflammation,    174 

caused    by    digitalis,    etc.,    drawbacks 

incidental     to,      162 — overcome     by 

combination    with    vaso-dilators,  163 

— caused    by    injection    of    adrenaline, 

160-1 

— of  vessels,  veins,  etc. — causes,  46; 
views  on,  of  Luchsinger  and  Schiff, 
and  of  Brunton  and  Fayrer,  128, 
note 

Contraction  and  dilatation,  nerves  gov- 
erning, 

— jn  heart,  45 

— in  vessels  of  the  heart,  ib. 
Contraction-wave  in  medusa,   29-30 
Convallaria   majalis    (lily   of   the   valley), 

uses  of,    146 

Convulsions,   caused  by  nicotine,    167 
Coronilla,     action     of — not     used     medici- 
nally,  146 

Coronary  arteries,  blocking  of — conse- 
quences, 96,  100,  105-6 

circulation     in,     connection     of,     with 

angina   pectoris,    189 
— consequences   of   interference    with, 

105-6 
— inadequacy    of,    in    cases    of    enlarged 

heart — consequences,    123 
— ossification    of,    in    relation   to    angina 
pectoris,    and    to    claudication,    ob- 
servations     on,      of      Jenner      and 
Parry,   cited  by   Brodie,    116,    189 
— quality  of  blood,  received  by,   94 
— how  they  supply  the  heart,   95-6 

right — interference     with     circulation 

in,    causing    cardiac    asthma — how, 
192 

terminal    branches   of,    communicating 

— consequences    of    closing    either, 
artificially  or  by   disease,   96,    105-6 
Corsets,     dangers    of,    during    administra- 
tion of  anaesthetics,    141 
— in   fainting,    141 
— in  flatulence,    141 
— in  palpitation,    141 
Cough,    due   to   over-smoking,    170 
Cougning,    process   of — effect   of,   on    pul- 
monary  circulation,    130 
Cranium  (sec  also   Brain),  pressure  within, 
variously      caused  —  bradycardia     in- 
duced by,    187-8 
Cupping,   dry,   possible  reasons  for  benefit 

from,    177 
— wet,    possible   reasons   for   benefit   from, 

177 
Curare,   effect  of, 

• on    medusas,    contractile   tissue,    30 

— on   motor  nerves,   30 
Curate,    jilting    by,    of   fiancee,    physiolog- 
ical results,   105 

Czermak,  Professor,  experience  of,  as  to 
compression  of  the  vagus  producing 
feeling  of  oppression,  121,  and  note 

DANCING-PARTY,  effect  of,  on  Girl's  heart 
— not  produced  in  same  case  by 
lawn-tennis,  126 

Death,  common  causes  of,  in  old  age,  209 


Death,   emptiness  after,  of  arteries,   2,   5 

— sudden,    forms   of   cardiac   disease    most 

liable  to,    196 

— from   drinking  large  quantities  of  al- 
cohol  at  one  time — analogy,    113 
— from   rupture  of  vessel  in   brain,   206 

Debility,  association  with,  of  palpitation, 
112;  treatment,  183 

— dilatation  of  the  heart  due  to,    126 

— general,  cardiac-weakness  due  to,  caus- 
ing bradycardia,  108,  186-7 

Decay,  see  Senile  Decay 

Degeneration  in  arterial  walls,  in  the  old, 
89,  99,  100-1,  115-6,  205-7,  (fig.)  98 

Depressor  nerves,   functions  of,    17 

Diabetes,  bradycardia   associated   with,  186 

Diaphragm,  movement  by,  of  viscera,  in 
upright  and  in  recumbent  position, 
133 

— upward  pressure  of,  in  flatulence  from 
disordered  circulation — -consequences, 
131 

Diastole,  defined,  3 

coincidence    with,    of    radial    pulse — 

when   found,  92 

more  complete — how  secured  by  dig- 
italis, 148 

— in  dog's  heart,  effect  on,  of  digitalis — 
deductions  as  to  arterioles,  158 

— in  frog's  heart,  reduplication  caused  by 
stimulus,  34,  (fig.)  35 

Diastolic  murmur  over  aorta,  significance 
of,  I9S 

Diastolic  and  systolic  pressure  in  arteries, 
how  estimated,  71,  (fig.)  70 — relation 
between,  at  highest  and  lowest,  82 

Dicrotic  wave,  the,  what  it  means,  and 
how  caused,  92,  (fig.)  90 

Diet  and  massage,   141   et  seq. 

— in   angina  pectoris,    191-2 

— chloride-free,   in   mitral   disease,   204 

— for  gouty  sufferers  from  paroxysmal 
tachycardia,  184 

— milk,  useful  in  sleeplessness  in  cardiac 
disease,  193,  and  see  204 

• — in  Nauheim  treatment,  201 

— nitrogenous,  injurious  in  cases  of  ar- 
terial high  tension  (Haig),  207-8 

— in  palpitation  of  the  heart,    181-3 

Digestibility  of  food  essential  in  angina 
pectoris,  191 

Digestion,  adjustment  of,  essential  to 
permanent  relief  of  palpitation— ^pre- 
scription, 181-3 

- — Improved,    due    to    absolute    rest,    and 

massage,   138 
— due   to    digitalis,    153-4 

• — in  stomach,  how  long  after  meal  before 
completed,  181-2 

Digestive  ferments,  use  of,  in  certain 
forms  of  tachycardia,  185 

— period,  slightest  exertion  during  and 
immediately  after,  causing  angina 
pain,  189;  precautions  requisite,  192 

Digit  or  limb,  compression  of,  for  meas- 
uring human  blood-pressure,  60,  61, 
68  et  seq. 

Digitalin,  action  of,  on  embryonic  and 
on  adult  heart — Pickering  on,  147-8 

Digitalis, 

— action,  uses,  etc.,  of, 

in  aortic  regurgitation  (uncomplica- 
ted) alone,  and  in  combination, 
196-7 

on  arterioles,   1 57-8 

stages  in,    158-60,    (figs.)    156,    157, 

158 


244 


THERAPEUTICS    OF    THE    CIRCULATION 


Digitalis,   action,   uses,   etc.,   of,    Brunton's 
experiments    on — case    of    regurgitant 
murmur    in     heart    of    dog    poisoned 
with,  due  to  irregular  action  of  mus- 
culi   papillares,    126 
— in   cardiac  asthma,    193 
•. as    cardiac    tonic,     146 — nutritive    ac- 
tion   of,     98 — strengthening    effect 
first  proved  by  author,    146 
— frog's    heart,     in    situ,     148 — excised, 
147-8,    160 

on  kidneys,   150,  152,   160 

— in   mammals,    149-50 

on  the  medulla,   149,   155 

— in    mitral    incompetence  —  aggravated 
cases,   197 

in  oedema,    152-4 

— resume  of,   147-8 
- — changed  view   regarding,    146 
- — different     effects     of     small     and     large 

doses  of,   on    nervous   system,    149 
• — good   effects   of,    enhanced    by    addition 

of   mercury,    203 

• — organs  affected   by,    147,    150,    160 
- — physiological    action    and    uses    of,    ex- 
periments on — double   action   of,   and 
tonic    effect    first    proved    by    author, 
146,  and  note,   150-2 

— poisons   having   similar   effects   to — used 
and     unused — vegetable,     and     from 
toad's  skin,    146-7 
— toxic   action  of,    154-6 
— in    animals — effect   on    apex -beat,    112 
— in    man — effect    on    pulse    in,     1 10-1, 

(figs.)    in,    160 
— uses  of,   150-2 

Digitalis  in  combination  with  powdered 
squill  and  blue  pill — value  of,  as  pill, 
in  cardiac  disease,  203 

with    "•  pulvis    mirabilis "    for    feeble 

heart,   181 

Digitalis  and  its  congeners,  amplitude  of 
pulse,  how  increased  by,  102 

differences   between,    160 

drawbacks  to   the  action   of,    162-3 — 

how  removable,   163,  203 
— importance  of,   146 
Dilatation,    see    also    Distension,    Vascular 

Dilatation   and   Vaso-dilators 
— of  arterioles,  due  to  local  irritation,  ob- 
versation    on,    of    Brunton,    Gunning 
and   Cohnheim,   46 

rdue  to  migraine,   no 

— of    capillaries,     as     affecting    sphygmo- 

grams,   90,    (figs.)    88,   89 
— power  of  nitrite  of   amyl   to  produce, 

163 

— central,   with   peripheral    contraction,    of 
arteries  of  head  and  neck — cause   of 
migraine,   in   author's  view,    119-20 
— of  heart — causes  and  consequences,    123 

— lessened   by    digitalis,    150 

right    side    of — a    cause    of    venous 

stasis,  202 

permanent,       caused       by      chronic 

bronchitis    or    spasmodic    asthma, 
13° 
— nerves    causing  —  explanation,    general, 

and    Brunton's  views,   45-6 
— of    ventricle    from    regurgitation    with 

stenosis,    122-3 

— of  vessels — aim  of  treatment  in   attacks 
of  angina  pectoris — methods  for,    189, 
191 
— by     heat,      174,      175 — how     affecting 

local    inflammations,    174 
Dilating  nerves,   45 


Dilating  power  of  blood-vessels,  apart 
from  influence  of  nervous  system,  47 

Dilute  hydrocyanic  acid,  use  of,  in  cer- 
tain forms  of  tachycardia,  185 

Dimethylxanthine,  or  theobromine  —  use 
of,  145 

Diphtheria,  weakness  of  the  heart  after 
— double  cause  of,  105,  107 — brady- 
cardia  induced  by,  108 

Diphtheria  antitoxin  —  urticarial  rashes 
common  after  injection  of,  118  • 

Discomfort  experienced  in  cases  of  val- 
vular disease  under  absolute  rest 
treatment  —  causes,  132-3  —  relieved 
by  massage,  134-8 

— without  pain,  frequently  felt  by  the 
heart,  and  other  hollow  muscular 
organs,  120-1,  and  see  126 

Diseases  (see  also  Cardiac  Diseases),  and 
conditions  in  which  fatty  degenera- 
tion of  the  heart  is  found,  96,  99, 
100,  105-6 

Disgust,   as  affecting  the  stomach,   104 

Distension, 

• — abdominal,  effect  of,  on  heart  and 
lungs,  131,  138 

— from  within,  of  hollow  muscular  or- 
gans— intense  pain  produced  by,  120 

— of    stomach,    angina   pain    increased   by 

— why,   189 

— causes,  consequences,  and  treatment, 
120,  131,  138,  139,  140,  141.  180, 
189.  193 

Diuretic  action  of  digitalis,  causes — thirst 
induced  by,  150,  152-3 

— action  of  purins,   161-2 

— effect  of  venous  congestion — overcome 
by  digitalis,  150-1 

Diuretics,  synthetic  compounds  as — how 
employable,  162 

Diuretin,  nature  and  uses  of,    162 

Dog,   blood-pressure  in,  6p 

— circulation  in,  maintained  by  vessels 
of  Thebesius  on  obstruction  of  coro- 
nary arteries,  96 

— heart  of,  effect  on,  of  injection  into 
veins,  of  digitalis  (Brunton  and 
Meyer),  158,  (figs.)  156,  157-9 

regurgitant    murmur    in    healthy,    due 

to     digitalis     poisoning     (Brunton), 
126 

— vena  cava  in  —  Ranvier's  experiment 
on,  as  to  dropsy,  153 

Dogiel,  experiments  of,  on  first  sound  of 
heart,  41-2 

—views  of,  on  importance  of  cardiac 
ganglia,  32,  note 

Double  nature  of  the  heart,  44 

Down  Bros.,  Von  Basch's  latest  sphyg- 
momanometer  obtainable  from,  68, 
note 

Drainage  tubes,  Southey's  or  Bartel's, 
for  leg's  or  scrotum,  204 

Drinking  large  quantities  of  alcohol  at 
one  time  causing  speedy  death — 
analogy,  113 

— at  meals,   to  be  given  up — and  why, 

• in   indigestion,    181-2 

— in   palpitation,  ib. 

— instances  of   danger   from,    140,    141 

Dropsy  (see  also  Ascites,  and  (Edema), 
chlorides  disadvantageous  in  —  why, 
204 

— Ranvier's  experiment  on  —  deductions, 
153 

Drugs  (see  also  under  Names),  causing 
absorption,  best  suited  to  cases  of 


INDEX 


245 


high  blood-pressure  due  to  gouty 
kidney  disease,  101 

Drugs,  use  of,  in  cardiac  diseases — clas- 
sification, 141  et  seq. 

—used  in  treating  palpitation,  172,  179- 
80,  183 

Drowsy  sleeplessness,  occurring  with  car- 
diac disease — how  aggravated — how 
relieved,  193  et  seq. 

Du  Bois  Reymond's  observations  on  the 
arteries  of  his  own  head  in  migraine, 
119 

Dudgeon's  sphygmograph,   93,    (fig.)   94 

Dunstan,   Prof.,  see   Cash  and  Dunstan 

Duodenum,  poisonous  substances  from 
liver  via  bile — reabsorption  of,  by 
liver  —  risks  of,  in  angina  —  how 
dealt  with,  191 

Dyspepsia,  chronic  bradycardia  induced 
by,  109,  187 

— great  rule  in  all  kinds  of — no  liquid 
during  meals — why,  181,  182 

— treatment  of,  in  certain  forms  of  tachy- 
cardia, 185 

Dyspnoea,  cardiac,  associated  with  mitral 
obstruction  and  regurgitation,  128-9 

EATING,  slowness  in,  requisite  in  cases 
of  palpitation — why,  181,  182 

Effusion  (see  also  Transudation)-  of 
lymph — with  vascular  dilatation — ail- 
ments due  to,  117 

— arrest  of,  by  digitalis,  153 

Eggs,  as  chloride-free  food — how  pre- 
pared, 204 

Eichhorst,  fatty  degeneration  in  fowl's 
heart  found  by,  on  section  of  vagi, 
105 

Elasticity  of  arteries,   etc.,   4 

as  affected  by  age,  89,  116,  205, 

(fig.)  88 

as  affected  by  Bright's  disease,  90, 

(fig.)  88 

in   relation   to   contractile   force,    to 

Elderly  people  (see  also  Age,  Old  Age 
and  Senile),  aortic  obstruction  in — 
how  caused,  122;  regurgitation  not 
necessarily  resulting,  122-3 

circulation  of,  as  affected  by  grief, 

worry  and  anxiety — case  in  point, 
104 

Electrical  stimulation  of  frog's  heart, 
effects  of  (Brunton  and  Cash),  33, 
34,  (figs.)  35 — deductions,  34,  35 

Elimination  of  waste  products  in  cardiac 
disease  by  purgatives,  203 

Eliminatory  function  of  kidneys,  inter- 
fered with  by  disordered  circulation 
— consequence,  131 

Elongation   of  muscle(?),   45,    (fig.)    46 

Embolism    in    coronary    artery — result,    96 

— obliteration  of  blood-vessels  caused  by 
- — gangrene  resulting  from,  115 

Embryonic  heart,  action  on,  of  cardiac 
tonics,  Pickering's  observations  on, 
147-8 

— aortic  orifice  sometimes  inflamed  in — 
consequence,  122 

— structure  of,  modifications  in  as  affect- 
ing pulsation  (Gaskell),  23-6 

Emetics,  attacks  of  paroxysmal  tachycar- 
dia sometimes  cut  short  by — those 
suitable,  184-5 

Emotional  causes,  angina  pectoris  brought 
on  by — historic  (fatal)  case,  189 

-^-nervous  depression  from,  effect  of,  in 
disease  of  the  circulation,  104 


Emotionalness  in  Graves's  disease — drugs 

beneficial  against,   184 
Emotions,   association  of,  with  vagus,  104, 

121 
Emphysema,   bradycardia   caused  by,    109, 

188 
— conditions     present     in,     affecting     first 

heart    sound,    43 
- — strain   due   to — effect  of,   on  right   side 

of  heart,    130,  202 
Enemata    of    tobacco,    former    uses    of — 

dangerous,  168 
Enfeeblement   of   vessels,    fourth   stage   of 

action  of  digitalis,    160 
Engelmann,    views    of,    on    movements    of 

the  heart,   18 
Engorged     conditions    of     right     side     of 

heart,   high  value  in,  of  blood-letting, 

177 

Enteric  fever,   see   Typhoid 
Entero-hepatic        circulation  —  absorption, 

excretion,     and    reabsorption    in,    by 

liver    of     substances    with     poisonous 

action — risks    from,    in    angina — how 

eliminated,   191-2,    (fig.)   192 
Epicardium,   as  affected  by  cocaine    (Von 

Basch  and  Frolich),    171 
Epilepsy,   bradycardia  occurring  in,    188 
Epileptic    symptoms,  Raynaud's    disease  as- 
sociated with,   117 
Ergograph,   Mosso's,   137,   (fig.)   136 
Erlanger's     modification     of     Riva-Rocci's 

sphygmomanometer,   81 
Erythrophlaeum    guinense,    medicinal    use 

of,    146;    principal    action   of,   on   the 

vessels,   160 
Ether,    effect   of,    on   medusae    (contractile 

tissue),  30 
Ethyl,     iodide     of,     use     of,     in     cardiac 

asthma,   193 
Evacuation,    arrangements    for,    in    cases 

where    recumbency    or    fixed   position 

must   be   maintained,    132-3 
Excitement,    simple,   as   affecting  the  kid- 
neys,  104 

— soothing  effect  in,   of  smoking,   169 
Exercise,   aid  given  by,  to  circulation,   6, 

131 
— excessive,     persistent     rapid     action    of 

heart   after  —  probable  cause  —  treat- 
ment,  184 
— plus  late   hours  and   emotion,   effect  of 

on     girl's     heart — not     produced     by 

lawn-tennis,   126 

Exercises,    in    and    after,    Nauheim    treat- 
ment, 200  et  scq. 
— in    treatment    of    cardiac    asthma — why 

beneficial,   193 
Exertion,    angina   pectoris  brought   on   by 

• — why — when  most  easily,    189 
— inability  for,  in  old  persons — causes  of, 

(Brodie),   116 

— of  getting  into  bed,  sometimes  fatal,  132 
—of  going  upstairs — illustration  of,  131-2 
Extremities,  as  affected  by  Raynaud's 

disease,   117 
Exophthalmic    goitre     (see    also    Graves's 

disease),  effect  of,  on  the  circulation, 

107 
Eyeballs,    protrusion   of,    not   a   necessary 

condition  of  Graves's  disease,    183-4 

FACE,    flushing   of,    caused    by    nitrite    of 

amyl    (Guthrie),   163 
— tint  of,  in  persons  suffering  with  aortic 

regurgitation,  123 


246 


THERAPEUTICS    OF    THE    CIRCULATION 


Fagge  and  Stevenson,  experiments  of,  on 
frog's  heart  (in  relation  to  action  of 
digitalis),  146 

Failing  compensation  in  enlarged  heart, 
demanding  more  blood  —  conse- 
quences, 123 

Fainting,  corset-loosening  in — reason  for, 
141 

— tendency  to    (or  actual),  cause  of,    123 
- — stooping  position  to  avert,    115 

Fainting  persons,  best  position  for  re- 
storing, 115 

Faintness  in  warm  rooms,  how  induced, 
107 

Faivre  and  Albert,  experiments  of,  on 
blood-pressure  in  man,  60,  and  note 

False  vocal  cords,  raised  pressure  due  to 
closure  of — expiration  made  against 
in  coughing,  130,  and  note 

Fasciae,  action  of,  in  relation  to  circula- 
tion, 6,  131 

— hard,  inflammation  under,  why  re- 
lieved by  cold,  174-5 

Fasting  condition,  angina  pain  less  easily 
brought  on  by  exertion  in,  than  at 
and  after  digestive  period,  189 

Fatal  shock,  see  under  Shock 

Fatty  or  fibroid  degeneration  of  cardiac 
walls, 

bradycardia    apt    to    occur    with, 

108,    186-7 
— cardiac   asthma   caused   by,    192 

causes   and   consequences   of,    96, 

99,    100,    105-6,    130,    192,    207 
— diseases  and   conditions  in  which 
found,   ib. 

in     rabbits    on    section    of    vagi 

(Wassilieff),      105,      108,      109, 
184,   186-7 

— risk,   double,   in  cases  of,   in  use 
of  digitalis,    163 

Fayrer,  Sir  J.,  and  Lauder  Brunton,  re- 
discovery by,  of  independent  pulsa- 
tion of  veins,  18,  44,  127,  128,  and 
note 

Febrile  colds,  aconite  useful  in,  in  small 
doses,  171 

Feet,  immersion  of,  in  hot  water,  increas- 
ing pulsation  in  femoral  artery,  175 

— and  ankles,  oedema  of,  first  sign  of 
venous  engorgement — why — how  re- 
lievable,  129 

Femoral  artery,  pulsation  of,  increased, 
by  immersion  of  feet  in  hot  water, 
i7S 

Fermentation    in    stomach — arrest    of,    es- 
sential  to   permanent   relief  of  palpi- 
tation,  180 
— how  set  up — how  prevented,   181 

Fevers, 

• — cardiac  weakness  from — how  indicated, 
42 

— infective— heart  weakness  from,  caus- 
ing bradycardia,  108 

toxins  of,    degenerative   effect  of,   on 

the   heart,    100 

— rapidity  of  circulation  in,  to  what  due, 
107 

Fibers,  described  by  Purkinje,  35,  note 

Fibroid  degeneration  of  cardiac  walls, 
see  Fatty  or  Fibroid  Degeneration  _ 

— thickening  as  cause  of  high  tension  in 
chronic  interstitial  nephritis,  49 

Fibrils,  nervous,  in  arterioles,  45 

Fibrosis,  arterio-capillary  (Gull  and  Sut- 
ton),  nature,  causes,  and  results  of, 
101-2 


Fick's  instrument  for  estimating  blood- 
pressure  by  limb  compression,  71, 
(fig.)  68 

— spring  manometer  (kymograph),  59, 
(fits.)  58,  59 

Finger-bending  exercises  in  treatment  of 
venous  stasis,  described — wide  effect 
of,  202 

Fingers,  aspect  of,  in  Raynaud's  disease, 
117 

Flatulence,  aggravation  of  anginal  pain, 
189 

— aggravation  by,  of  drowsy  sleeplessness 
of  cardiac  disease — how  relieved,  193 

— due  to  disordered  circulation  alone,  or 
with  ascites,  effect  of,  on  the  heart, 
131.  139.  180 

precautions  against  in  diet  and  regi- 
men,   181-3 

prescriptions  in  relief  of,   180-1 

- — lessened  by  abdominal  massage,   138 

• — jessened  by  action  of  digitalis,   154 

- — in  stomach  and  intestine,  in  venous  en- 
gorgement, 129 

Flatulence-causing  foods — to  be  avoided 
in  angina  pectoris,  191;  in  palpita- 
tion, 181-2 

Flow  of  blood,  see  Blood  and  Circulation 

— lymph,  see  Lymph 

Fluid  (see  also  Drinking  and  Liquids), 
allowance  of,  in  various  cardiac  com- 
plaints, by  Dr.  Schott,  201 

Fluid,  drain  of,  from  blood  by  kidneys  in 
cardiac  disease,  how  supplied — and 
how  arrested  by  digitalis,  149,  150, 
151,  152,  160 

Fluid-pad  instruments  for  measuring  hu- 
man blood-pressure,  62  et  seq. 

Fluttering,  nervous,  of  the  heart,  quiet- 
ing effect  on,  of  very  small  doses  of 
aconite,  172 

Fatal  life  (see  also  Embryonic  heart), 
aortic  orifice  sometimes  inflamed 
during — consequence,  122 

Fomentation,  warm,  over  heart,  stimulat- 
ing effect  of,  178 

Food,  see  also  Diet 

- — chloride-free,  in  dropsy,  204 

— flatulence-causing,  to  be  avoided  in  an- 
gina pectoris,  191;  in  palpitation, 
181-2 

— proteids  in,  reduction  of,  advised,  in 
senile  rise  of  pressure,  208 

Force-storing  function  of  arteries,  4 

Fowls'  hearts,  fatty  degeneration  in,  on 
section  of  vagi  (Eichhorst),  105 

France,  attention  paid  in,  to  transudation 
as  affected  by  chlorides,  204 

Frangois's  instrument  for  measuring 
blood-pressure  in  a  limb,  71 

Frey,   Von,  see  Ludwig  and  Von  Frey 

Frog, 

— arterioles  of,  dilatation  in,  caused  by 
local  irritation,  observed  by  Gunning 
and  Cohnheim,  46 

— foot  of,  capillaries  in,  dilatation  of, 
caused  by  amyl  nitrite  (Richard- 
son), 163 

— heart    of, 

— apex,  dilatation  of,  by  pressure  from 
within — result,  28,   128 

effect  on,  of  aconite,   171 

of    compression,    as    to    passage    of 

stimuli,  31 

of   digitalis,    146-7,    149-50 

effect   on,    of    heat,    cold,    51,    (figs.) 

52-3,   and   poisons,   author's  instru- 


INDEX 


247 


ment  for  showing,    (fig.    and  note) 

21 

Frog,    heart    of,    effect    on — continued 

of  nicotine,    167-8 

of  shock — Goltz's  experiment  show- 
ing,  113 

electrical   stimulation  of,   experiments 

of  Brunton  and  Cash,   33-4,  (figs.) 
35 — deductions,    34,    35 
— of  auricle,   34,    (fig.)   35 
of  venous  sinus,  34,   (fig. 


5,  34,    (fig-)   36 
,  .(figs.)   35 


of  ventricle,  34, 

-excised,   or  isolated, 

— effect  on,  of  digitalis,    146-7,    160 

-Ludwig's  mode  of  keeping  alive  and 
in  action,  143,  (fig.)  142 

-pulsatile  pouches  on,  during  contrac- 
tion with  digitalis,  148 

-experiments  on,    and    deductions, 

author's,  instrument  used  in,   (fig.) 


-Bowditch's, 
(fig.)  22 


instrument     used     in, 


Gaskell's,   23,    25,   26,   31 

Fagge  and  Stevenson's  (as  bearing 

on  digitalis),   146 
— Stannius's  —  author's    diagrams    to 

illustrate,  20 
— Williams' s,  (fig.)  23 

movements  of,   investigation  of,   22 

(i)    nervous  control  theory    (Stan- 

nius),   21,    (diags.)    20 

. (2)     muscular     contraction     theory 

(Gaskell),  23-26 

parts    composing,    and    nerves    hypo- 

thetically  controlling,   19,  21    (figs.) 
19,  20 

stoppage  of,   due   to   digitalis — period 

at  which  occurring,    147-8,    160 

due  to  shock — consequences,  Goltz's 

experiments,   113 

vessels   of,    as    affected   by    heat   and 

cold,   51,   (figs.)    52-3 
— lymph  hearts  in,  9 

Frog's  lungs,  capillaries  of,  effect  on,  of 
heat  and  cold — author's  experiments 
on — deductions,  51,  (fig.)  54 
Frohlich,  A.,  and  Von  Basch,  experiments 
of,  on  action  of  cocaine  on  the  heart 
— deductions  from,  as  to  reflex  mech- 
anism in  heart,  171 

Functional  irritation  of  the  heart,  "  pul- 
vis  mirabilis  "  for  —  prescription — 
comments,  181 

— mitral  incompetence — causes  and  conse- 
quences, 124-5 

GAERTNER'S  aneroid  manometer,  portable 
form  of  his  tonometer,  76,  (fig.)  75 

— tonometer,    73-6,    (figs.)    74,   75,    76 

Gall-bladder,  discomfort  without  pain,  fre- 
quently felt  by,  120 

— effect  on,  of  (a)  pressure  from  without, 
120;  (b)  distension  from  within,  ib. 

Gall-duct,  discomfort  without  pain,  fre- 
quently felt  by,  1 20 

— effect  on,  of  (a)  pressure  from  without, 
120;  (b)  distension  from  within,  ib. 

Gangee,  Dr.  A.,  discoverer  of  power  of 
nitrite  of  amyl  to  lower  blood-pres- 
sure—experiments of,  on  author's 
pulse,  163 

Ganglia, 

— in  frog's  heart,  19,  20,  28,  29,  32,  note 

— in  medusa,  function  of,  29;  effect  on, 
of  nicotine,  30-1 

— peripheral,  dilatation   connected  with,  46 


Ganglion  cells  (see  also  Cardiac  Ganglia), 

share    of,    in    heart's   action,    24,    25, 

(fig-)  25 
Gangrene,  caused  by  severe  cases  of  Ray- 

naud  s  disease,   117 
— senile,   cause  of,   and  main   preliminary 

symptom    (Brodie),    116 
Gaskell,    experiments    of,    on    heart-beat, 

22,     III 

— views  of,  on  heart  of  embryo — devel- 
opment of,  25 

on  heart  movements  in  cold-blooded 

vertebrates,  23 

on  heart  movements  in  mammals,  18, 

19 

Gaskell's  clamp,  effect  of  applying  to 
frog's  heart,  31,  37,  note 

Gastric  irritation,  early  indication  of 
toxic  action  of  digitalis,  153-4 

— mucous  membrane,  treatment  to  soothe 
in  bradycardia  due  to  reflex  inhibi- 
tion from  stomach,  188 

— ulcer,  reflex  irritation  from  bradycar- 
dia due  to,  109,  187 

General  debility,  see  Debility 

General  paralysis  of  the  insane,  brain- 
pressure  due  to,  causing  bradycardia, 
109 

General  paresis,  bradycardia  occurring  in, 
1 88 

Getting  into  bed,  exertion  involved  in — 
sometimes  fatal  in  valvular  disease, 
132 

Giddiness,  causes  of,    123,    170 

Girl,  death  of,  from  being  jilted — physio- 
logical causes,  105 

— heart  of,  affected  by  evening  dancing, 
not  by  open-air  lawn-tennis,  126 

Gland,  see   Submaxillary 

Glendinning,  see  Williams,  C.  J.  B.,  and 
others 

Glomeruli,  rise  of  blood-pressure  in,  due 
to  digitalis— ^-consequences,  1 5 1-2 

Glucose  as  cardiac  nutrient,  Locke's  ex- 
periments, 145 


Gluteus  maximus  muscle,  function  of,   7 
Going    upstairs — work    involved    in— dem- 
onstration of,    131-2 


Goitre,   see  Exophthalmic  Goitre 
Goltz's  experiment  on  frog,   showing  two- 
fold action  of  blow  on  abdomen,   113 
Gouty  kidney   disease,    drugs  causing   ab- 
sorption, why  useful  in,  101 
Gouty    sufferers    from    paroxysmal    tachy- 
cardia,   diet   for,    185 

Graves's    disease    (see    also    exophthalmic 

Goitre),     palpitation     in,     and    other 

symptoms — best  treatment  for,    183-4 

Gresswell,    Dr.    (the  late),   of  Melbourne, 

see  Brunton  and  Gresswell 
Grief,   as  causing  sighing,    104 
— effect  of,  on  the  circulation,   104 
Grief  or  anxiety  (q.  v.),  sense  of  oppres- 
sion of  the  chest  from — to  what  due 
• — author's     observation     on     himself, 

121 

Guarana,  dietetic  use  of,   162 

Gull  and  Sutton,  originators  of  the  term 

"  arterio-capillary   fibrosis,"    101 
Gunning  and   Cohnheim,    experiments  of, 

on    dilation   of   arterioles    (frog's)    by 

local  irritation,  46 
Guthrie,  discoverer  of  face-flushing  power 

of  nitrite  of  amyl,   163 

ILEMODYNAMOMETER,   Marey's — how  used, 
(fig.)  55 


248 


THERAPEUTICS    OF    THE    CIRCULATION 


Haemoglobinuria,  Raynaud's  disease  fre- 
quently associated  with,  117 

Haemoptysis,  occurring  most  frequently  in 
mitral  obstruction,  128 

—profuse,    dicrotic   wave   in   case   of,   92, 

(fig-)  9i 

Haemorrhage,  cerebral,  bradycardia  occur- 
ring with,  187 

Haig,  Dr.,  cited,  on  injurious  effects  of 
too  nitrogenous  a  diet,  207-8 

Hale,  see  Williams  and  others 

Hales,  Rev.  Stephen,  inventor  of  the 
manometer,  10 

Haller,  acquainted  with  the  independent 
pulsation  of  veins  (1757),  18 

Hallion      and      Comte's     plethysmograph, 

(fig-)  73 

Hand,  effect  on,  of  plunging  into  hot 
water,  51 

Hand-pressure  over  heart,  as  cardiac  sed- 
ative, 178 

Harvey,  and  the  case  of  Lord  Mont- 
gomery— proof  that  external  pressure 
is  not  felt  by  the  heart,  120 

— cited  on  the  regulating  power  of  the 
arteries,  4 

— discovery  by,   of  the   circulation,   2 

Haustus  scoparii  compositus  of  St.  Bar- 
tholomew's Hospital,  as  eliminatory 
agent— composition,  203 

Hay,  Dr.  Matthew,  action  of  sodium  ni- 
trite first  described  by,  166 

Head,  lowering  between  hands  or  knees, 
to  avert  fainting — why  effectual,  115 

Head  and  neck,  arteries  of,  as  affected 
in  migraine — author's  view,  119 

Headache,  induced  by  nitroglycerine,    165 

— severe,  relieved  by  application  of 
leeches  over  mastoid  process,  177 

— sole  ill-effect  from  overdoses  of  nitro- 
glycerine or  amyl  nitrite,  191 

Healthy  man,  thirst  produced  in,  by  diu- 
retic action  of  digitalis,  150,  153 

— people,  character  of  sphygmograms  of, 
90,  (figs.)  88 

Heart,  see  also  Apex,  Cardiac  Dilatation, 
Dog's  Heart,  Embryonic,  Fatty  De- 
generation, Frog's  Heart,  Hypertro- 
phy, Palpitations,  Valvular  Disease, 
etc. 

— action  on,  of  aconite,   171,   172,   174 

of  adrenaline,   160 

of  caffeine,  etc.,   145.   161-2 

of  cocaine  —  experiments  of  Von 

Basch  and  Frohlich,  and  .  deduc- 
tions, 171 

of  digitalis,   145   et  seq. 

of  nicotine,    167 

of   strophanthus,    160 

of  strychnine,    161 

—adult  and  embryonic,  effect  on,  of  digi- 
talin,  Pickering  on,  148 

— auxiliary,  place  of,  supplied  by  mas- 
sage, in  treatment  of  venous  stasis, 
202 

— base  of,  aortic  regurgitant  murmur  at 
times  not  heard  at,  195 

— beating  of,  from  emotion,  stilling  of, 
by  hand-pressure  over,  178 

— benefits  to,  of  gentle  exercises,  in  car- 
diac asthma — how  produced,  193 

— and  blood-pressure    (q.  v.),  9 

— chief  function  of,  3 

— comparison  between,  and  a  medusa — 
experiments  of  Romanes.  26  et  seq., 
fig*- 


Heart,  contraction  in,  of  muscular  fibers, 
caused  by  digitalis — how  effected — 
results  as  to  pulse  and  beats,  149 

• — contraction  of,  effect  on,  of  massage 
and  exercises,  202,  (fig.)  198 

mode  of,  instruments  for  ascertain- 
ing, 84  et  seq. 

of  parts  of— sequence  of — source  of 

(Gaskell),  25 

under  normal  conditions  due  solely 

to  muscular  tissue?  or  no?  26 

— dependence  of,  on  due  pulmonary  aera- 
tion (Powell),  94 

— dilatation  of,  causes  and  consequence, 
123 

— discomfort  without  pain  frequently  felt 
by — illustrations,  120 

— diseases  of,  see  Cardiac  Diseases 

— double  nature  of,  44 

— effect  on,  of  flatulence,   139 

of  heat  and  cold,   51,   (fig.)    52-3 

of  over-smoking,    167-8 

— emotions  affecting,   104,   178 

— enlarged,  inadequate  supply  of  blood 
to — causes  and  consequences,  123 

— how  relieved  by  treatment,  in  attacks 
of  angina  pectoris,  189,  191 

— increased  work  of,  in  overcomine  ab- 
normally high  pressure  —  causes  — 
bradycardia  induced  by,  188 

— inhibitory  apparatus  in,  double  effect 
on,  of  nicotine — effect  on  pulse-rate, 
167 

excessive  action  of,  one  probable 

cause  of  slow  pulse,  186,  187 — how 
excited,  186 

— insensitiveness  of,  to  pressure  from 
without — historic  instance,  120 

— isolated,  effect  on,  of  cold,    107 

— mammalian,  compared  with  that  of 
frog,  19 

isolated,  Locke's  experiments  on — 

deduction  as  to  value  of  glucose, 

145 
— muscular  tissue  of,  as  affected, 

by    blocking    of    coronary    arteries, 

96,   100,   105-^6 

by  toxins  of  diseases,   too,  106 

— nervous  action  and  muscular  fiber  of, 
stages  of  action  of  digitalis  as  affect- 
ing, 159-60 

fluttering    of,    quieting    effect    on,    of 

very  small  doses  of  aconite,    172 
— nervous   and   muscular   conduction   in — 
experiments    of    Brunton    and    Cash, 
33i    34.   and   note,    (figs.)    35 — deduc- 
tions,  34,  36 

— power  of,  to  originate  intense  pain,  120 
— rapid  action  of,  characteristic  of  tachy- 
cardia— cause — treatment,    184 
— refractory  period  of,  4 

investigations   on,    of   Sanderson    and 

Page,  33 

pointed  out  by  Marey,  33 

— rhythmical  power  of,  effect  on,  of  Kro- 
necker  and  Schmey's  experiment, 
37-8 

— right  side  of — conditions  of,  causing 
cardiac  asthma,  192-3 

dilatation    of,    one    cause    of    venous 

stasis,  202 

permanent,      induced      by      chronic 

bronchitis  and  spasmodic  asthma 
— why,  130 

engorged    conditions   of — blood-letting 

in — benefits  from,   177 


INDEX 


249 


Heart,   right  side  of — extra  tension  in,  in 

recumbency,    effect   of    (Hill),    133 
— self-massage    of,    in    relation    to    nutri- 
tion,  96-8 

possibly    inducible    by    inhalation    of 

oxygen,  203 

• — sensitiveness  of,    120-1 
— sleep  of,  duration  of,  3,  9 

maintenance  of  circulation   during,  4 

- — sounds  of,  41  et  seq. 
— stimuli  in,  transmission  of,  32,  and  note 
— stoppage  of,   caused  by, 
— blow   on   abdomen,    113 

drinking  large  quantities  of  alcohol 

at  a  draught,    113 

imperfect   anaesthesia,    1 13 

severe  pain,    1 13 

reflex,  in  imperfect  anaesthesia  unac- 
companied by  reflex  contraction  of 
vessels — author's  view,  1 13-4 

risk     of     causing,     by     digitalis,     in 

Bright's  disease,    163 

— strengthening  of,  aim  of  all  treatment 
for  bradycardia — drugs  best  adapted 
for,  1 88 

— suction  exerted  by,  during  ventricular 
constriction,  assistance  of,  to  circu- 
lation, 5 

— tilting  up  of,  by  flatulence — cause  and 
consequence,  131,  140 

by    stomach-distension  —  anginal    pain 

increased  by,   189 
— valves  of   (q.  v.),  39-40 
— various    helping    agencies    in    work    of, 

5  et  seq. 

— walls  of,  see  Cardiac  Walls 
— weak  or  feeble,  see  also  Cardiac  Weak- 
ness 

stimulation     of,     local,     external,     by 

various    applications     of    heat,     or 
heat-producers,   178 

— work   of,   increase  of,   by   digitalis,   etc., 
in  raising  blood-pressure — risks  from, 
i62-3: — how   overcome,    163 
Heart  and  vessels,  both  acted  on  by  digi- 
talis,  1 60 

combined  effect  on,  of  rest  and  mas- 
sage, 137-8 

coordination  between,  how  maintain- 
ed, 13-15 

Heart-beats,   see  also  Pulse-beats 
— acceleration    of — proportionate    exhaus- 
tion, 3-4 
— in  frog's  heart,   as  affected  by  aconite, 

.T72     . 

— origination  of,   17,  44 
• — -quickened   by   caffeine — why,    162 
Heat,  see  also  Hot  Water 
- — modification  by,   of  local   circulation  in 
inflammation  —  when    of    use  —  why, 
174-5 

— vascular   dilatation   caused  by,    107 
Heat  and  cold,  effect  of, 

an  circulation,    51,    (figs.)    50,   52-3 
n    frog's    lungs — author's    experi- 
ments,  56,    (fig.)   54 
an  muscular  tissue,   50,    (figs.) 
on  pulmonary  capillaries,   51,    (fig.) 
54 

on  pulse-rate,   106-7 

Heat,    cold,    and    poisons,    action    of,    on 
frog's  heart,   author's  instrument  for 
showing,    (fig.  and  note)  21 
Helleborus   niger    (Christmas   rose),    uses 

of,    146 
Hemiplegia,   see   also   Paralysis 


Hemiplegia,  resulting  from  rupture  of 
blood-vessel  in  brain,  205 

— transient,  Raynaud's  disease  associated 
with,  117 

Hepatic  plexus,  see  Coeliac,  Hepatic,  and 
Splenic  Plexus 

Hepatitis,  relief  in,  alone  or  with  peri- 
hepatitis,  from  application  of  leeches 
over  liver,  177 

Herisson's  sphygmomanometer,  (fig.)  62, 
63,  68 

High  pressure,  see  Blood-pressure,  high 

High  tension,  see  arterial  tension,  high 

Hill,  Leonard,  cited  on  cause  of  intoler- 
ance of  recumbent  position  by  suf- 
ferers from  severe  valvular  disease, 
133 

— instrument  of,  for  measuring  blood- 
pressure,  68-9 

Hill  and  Barnard's  modification  of  the 
Riva-Rocci  sphygmomanometer,  78 

His,  William,  neuro-muscular  bundle  de- 
scribed by,  35,  note 

Hoarseness  due   to  over-smoking,   170 

Hollow  muscular  organs — discomfort  with- 
out pain,  frequently  felt  by,  120 

distension  from  within  productive 

of  intense  pain,  120 

pressure  on  from  without  not  pro- 
ductive of  pain  in,  120 

Hope  as  affecting  the  heart,   104 

Horse,  blood-pressure  in,  60 

Hot  food,   not  sleep-producing — why,    175 

Hot  water,  immersion  of  feet  in,  causing 
increased  pulsation  of  femoral  artery, 
175 

with  lemon,  how  and  when  to  be 

drunk  by  the  flatulent,  182 

Hot-water  bap,  action  of  weak  heart  stim- 
ulated by,  178 

Huka,  or  narghileh,  smoking^  with — inha- 
lation in,  169 

Hunter,  John,  death  of,  from  angina  pec- 
toris  brought  on  by  anger,  189 

— observation  by,  on  flow  of  blood  dur- 
ing syncope,  115 

Hurtle,  manometer  of,  60 

Hyaline  tissue,  deposit  of,  in  coats  of  ar- 
terial walls,  due  to  kidney  disease — 
effects,  101 

Hyderabad  chloroform  commission,  find- 
ing of,  on  risks  of  giving  anaes- 
thetics without  removal  of  corsets, 
141,  and  note 

Hydrocyanic  acid,  dilute,  use  of,  in  cer- 
tain forms  of  tachycardia,  185 

Hydroxylamine,  a  yaso-dilator,   166 

Hyoscyamus,  addition  of,  to  purgative 
pill — aim  of,  203 

Hypertrophy  of  auricle,  caused  by  mitral 
obstruction,  127-8,  and  by  mitral  re- 
gurgitation,  127 

— of  heart,  inadequacy  to,  of  normal  cor- 
.  onary  artery,  96 

palpitation  rare  in — why,   112 

some  causes,  and  their  effects,    101-2 

— of  ventricle,  in  aortic  regurgitation,  to 
what  due — compensatory  advantages 
of,  122 

Hypnotics,  useful  in  treatment  of  sleep- 
lessness in  cardiac  disease,  193 

Hypoxanthine  and  other  purin  bodies — • 
use  of,  145 

ICE-BAG  over  heart,  sedative  effect  of,  178 
Iced    water,    drinking    of,    in    paroxysmal 
tachycardia,   benefit  of,    184 


250 


THERAPEUTICS    OF    THE    CIRCULATION 


Incisions    for    oedema    of    legs — methods, 

204 

Incompetence,  see    Aortic,  Mitral,  Valvular 
Indigestion,    see    Dyspepsia 
India-rubber  ice-bag   over   heart,   sedative 

effect  of,   178 
— tube  coiled  to  form  flat  plate,  with  cold 

water    passed     continuously    through 

it,  as  local  cardiac  sedative,   178 
Infective    diseases, 

cardiac    weakness    from — bradycardia 

occurring  in,    186-7 

fatty   degeneration   of  the   heart   fre- 
quent in,   100,   105 
Inflammation     of     aortic     orifice     during 

fatal   life — consequences,    122 
— chronic,   of  the  brain,   bradycardia   due 

to,   109 

— local,  use  of  aconite  in,   172,   174 
— of    mitral   valves,    narrowing   of   orifice 

from — -consequences,    127 
— modification    of    local    circulation    in — 

methods  explained,   174-5 
Inhalation  of  oxygen  in  cardiac  asthma — 

remarkable  benefit  of,    193 
- — in    venous    stasis,    action    possibly    in 

part  mechanical,  203 

— in    smoking,    with    huka    and    with   cig- 
arette— objections  to,   169 
Inhibitory  apparatus  in  the  heart — double 

action     on,     of    nicotine  —  effect    on 

pulse-rate,   167 

in  medulla  or  in  heart,  excessive  ac- 
tion of,  probably  cause  of  extreme 
slowness    of   pulse,    186,    187 — how 
excited  in  the  latter,   186 
— center  of  vagus,  as  affected  by  digitalis, 

149 

— neurons  still  susceptible  to  local  stimu- 
lation after  large  dose  of  nicotine, 

though  inhibitory  ganglia  of  heart  be 

paralyzed  by  drug,    168 
Injuries    of    cervical     cord,     bradycardia 

occurring  in,    188 
— of    medulla,    bradycardia    occurring    in, 

1 88 
Insensitiveness   of   the    heart   to   pressure 

from    without — historic   instance,    120 
Instruments  for  measuring  blood-pressure 

in   man,   two   classes   of,    descriptions 

and  uses   of,   60   et  seq. 
— standardization  of,   82 
— used  in  tapping,  204 
Intercostal    space,    second,    second    heart 

sound  best  heard  at,  42 
Intermittent    fever,    pulse    in,    tracing   of, 

(.fig.)  89 
— pulse    (.see   also   Irregularity  of  Pulse), 

varieties  of,   no 
causes  uncertain — author's  own  view, 

112 

Intestines  (.see  also  Stomach  and  Intes- 
tines), congestion  of — diminished  by 
rest  and  massage,  138 

— discomfort  without  pain  frequently  felt 
by,  1 20 

— effect  on,  of  (a)  pressure  from  without, 
120;  (b)  distension  from  within,  ib. 

— flatulence  in,  in  venous  engorgement, 
129 

— reflex  stimulation  of  medullary  vagus 
center  from — bradycardia  caused  by, 
187 

Involuntary  muscular  fiber,  in  relation  to 
endurance  of  strain,  128 

Iodide  of  ethyl,  use  of,  in  cardiac  asthma, 
193 


Iodide  of  potassium,  useful  in  cardiac 
asthma,  193 

Iodides,    suitability   of,    in    cases   of   high 
blood-pressure    due    to    gouty    kidney 
disease,   102 
— in   senile   high  tension,   208 

Iron,  strychnine  with,  in  treatment  of 
bradycardia,  188 

Irregular  action  of  musculi  papillares, 
regurgitation  due  to — author's  obser- 
vations on,  and  others',  126 

Irregularity  of  the  heart  (or  pulse),  com- 
mon in  over-smoking,  170 

forms    of — causes — persistence — treat- 
ment— instances,    1 88-9 

more  frequent  in  mitral  than  in  any 

other     form    of    cardiac    disease — 
why,    126,    128 

Irregularity  and  quickening  of  pulse 
caused  by  large  doses  of  aconite — 
why,  171 

Irritability,  see  also   Nervous  Irritability 

— of  arteries  in  cases  of  aortic  regurgita- 
tion, 123 

— of  patients  in  absolute  rest  treatment 
- — causes,  134 — relieved  by  massage, 
137 

— of  throat,   due  to  over-smoking,   170 

Irritants,  inside  stomach  or  intestine — 
effect  of,  similar  to  that  of  blow  on 
stomach,  113 

Irritation,   see  also    Stimulation 

— of  arterioles — local  effects,  as  observed 
by  author,  46 

— of  chorda  tympani,  effect  of,  on  arte- 
rioles of  submaxillary  gland  and  on 
condition  of  gland — a  parallel,  115 

— of  heart — functional — an  excellent  rem- 
edy for — prescription — comments,  180 

— of  nerves,  severe  pain  from — effects  of, 
on  heart,  113 

— reflex,  from  stomach,  as  cause  of  par- 
oxysmal tachycardia — treatment,  185 

from    various     organs    and    sources, 

bradycardia  due  to,   109 

• — of  stomach,  local,  induced  by  toxic  ac- 
tion of  digitalis — parallels,  155 

— of  tongue,   due  to   over-smoking,    170 

— of  the  vagus   (mechanical ,>,  or  pressure 
on,    feeling    of    oppression    of    chest 
caused    by- — author's    observations    on 
himself  — •  Czermak's     personal     expe- 
rience,  121,  and  note 
— prolonged    systole    (dog's    heart),    se- 
cured by,    1 58 

— of  vagus  center  in  medulla — bradycar- 
dia caused  by — how,  109 

caused    by     excessive     tension — re- 
sults,  15 

caused  by  toxic  action  of  digitalis, 

iSS 

— of  vagus  roots,  reaction  of,  on  speed 
of  heart,  15,  {fig.)  14 

— of  vagus  trunks,  branches,  or  ends,  in 
cardiac  plexus — effect  of,  on  speed 
of  heart,  15,  186,  (fig.)  14 

JACQUET'S  sphygmograph,  93 

Jalap  powder,  compound,  203 — addition 
to,  of  bitartrate  of  potassium — advan- 
tage of,  203 

Janeway's  and  others'  modifications  of 
the  Riva-Rocci  sphygmomanometer, 
81 

Jaundice,  bradycardia  in — how  caused, 
109,  187 


INDEX 


251 


Jenner,  Dr.,  observations  of,  cited  by 
Brodie  on  cause  of  angina  pectoris, 
116 

Jones,  Wharton,  rhythmical  contractions 
in  veins  observed  by,  46,  123 — cause 
of,  according  to  Luchsinger  and 
Schiff — observations  of  Brunton  and 
Fayrer  referred  to,  128,  note 

Joy,  as  affecting  the  heart,   104 

KENT,  STANLEY,  and  His,  neuro-muscular 
bundle  described  by,  35,  note 

Kidney  action,  aided  by  compound  jalap 
powder,  203 

Kidney  disease,  deposit  in,  of  hyaline  tis- 
sue in  coats  of  arterial  walls — effects, 
101 

gouty,  tension  due  to  the  above  de- 
posit, drugs  best  suited  to  relieve, 

IOI-2 

Kidneys   (see  also   Renal  Vessels),  action 

on,      of      macrophags,      in      old      age 

(Metchnikoff),  206-7 
— arteries    of,    as    affected    by    Raynaud's 

disease,   117 
— effect  on,   of   disordered   circulation,  131 

of  massage  during  rest,   138 

of  mere  excitement,    104 

of    venous    congestion — overcome    by 

digitalis,   150-1 

of  venous  engorgement,    129 

— secreting    cells    in,    action    of    caffeine, 

etc.,    150,    161-2 

— of  digitalis,    150,    152-3,   160 

— of  purin  bodies,    161-2 
Kocher,   opinion   of,   as  to  drugs  used  in 

Gravea's  disease,   184,  and  note 
Kola,  dietetic  use  of,   162 
Kronecker    and    Marey,    discovery    by,    of 

refractory   period   of  the  heart,   33 
Kronecker    and    Schmey,    experiment    of, 

on     puncturing    point    in     septum    of 

ventricles — effect    of — deduction  from, 

37 

Kymographs,  see  also   manometers,  etc. 
— Brunton's  combination  of  Ludwig's  and 

Pick's,    (fig.)    59 
— how  used,  60 
— Ludwig's,    ID,    (figs.)    ii,   56 
— oscillations    in,    of    mercury,    57,     (fig.) 

57,  how  avoided,   59 

LACTOSE  in  milk,  apparent  diuretic  action 
of,  204 

Lads,  growing,  harmfulness  to,  of  to- 
bacco-smoking, 169 

Laulanie's  sphygmograph,  digital,  94, 
(fig.)  95 

Lead-poisoning,  bradycardia  caused  by, 
109,  187 

Leech,  Prof,  (the  late),  lectures  of,  on 
drugs  of  the  nitrous  group,  referred 
to,  166 

Leeches,  application  of— cases  in  which 
beneficial,  177 

Left  side,  lying  on,  causing  palpitation, 
1 1 2-3,  179 

Legs,  muscles  of,  accessory  to  circula- 
tion, 6,  7,  131 

— tapping  of,    for  oedema — method,   204 

— raising  of,  effect  on  tension  in  vena 
cava,  129,  133 

Life,  prolongation  of,  by  attention  to  ar- 
terial conditions,  205,  208-9 

Ligaturing   coronary   arteries — results,    96 

Lily  of  the  Valley  (Convallaria  mafalis), 
uses  of,  146 


Limbs,  circulation  in,  feeble  in  absolute 
rest  treatment — consequences,  134 — 
relieved  by  massage,  135-8 

Limbs,  reduction  in  size  in,  when  brain 
is  active — Mosso's  demonstration,  114 

Lime  in  saline  solution,  benefit  of,  in 
artificial  circulation — Ringer's  discov- 
ery, 143 

Liquid  with  meals  to  be  avoided  by  the 
flatulent — why,  180,  181 

Liver,  attention  needed  by,  in  relief  of 
palpitation — why,  181 

— application  over,  of  leeches,  in  relief  of 
hepatitis,  177 

— congestion  of,  diminished  by  rest  and 
massage,  138 

— distension  or  swelling  of,  due  to  in- 
creased blood-pressure,  17 

due   to   venous   congestion — overcome 

by  digitalis,   154 

— excised,  secretion  by,  of  bile — experi- 
ments on,  of  Ludwig  and  Schmule- 
witsch,  1 6 

— functions  of,  interfered  with  by  disor- 
dered circulation — injurious  reaction 
on  the  heart,  131 

— poisonous  substances  absorbed  by,  ex- 
cretion of,  and  reabsorption — risks 
from,  in  angina  pectoris — how  elimi- 
nated, 191 

— reflex  irritation  from,  bradycardia  due 
to,  109 

Liver  and  portal  system,  as  affected  by 
venous  engorgement,  129 

Llangammarch,  graduated  walks  at,  for 
Oertel's  treatment,  202 

Local  action  of  nicotine  on  arterioles,  167 

— applications  over  cardiac  region,  of 
pressure,  heat,  and  cold,  benefits 
from,  177-8 

of  cold,  effect  of,  on  an  artery,   175, 

(fig.)  176 

— asphyxia,  occurring  in  Raynaud's  dis- 
ease, 117 

— bleeding  by  leeches,  and  cupping — cases 
in  which  beneficial — action  not  un- 
derstood, 177 

— inflammations  with  general  febrile  dis- 
turbance, use  of  aconite  in,  172,  174 

— modification  of  the  circulation,  in  in- 
flammation, various  methods  of,  ex- 
plained, 174-5 

— paralysis  resulting  from  rupture  of 
blood-vessel  in  brain,  206 

Locke's  experiments  on  glucose  as  cardiac 
nutrient,  145 

Luchsinger  and  Schiff,  observations  of, 
on  cause  of  rhythmical  contraction  in 
veins,  128,  note 

Ludwig,  Prof.,  demonstration  by,  on 
cause  of  mitral  incompetence,  125 

— experiments  of,  on  cause  of  first  sound 
of  heart,  42 

— invention  of,  for  keeping  isolated  or- 
gans alive  by  artificial  circulation — 
methods  and  means,  143,  (fig.)  142 

— kymograph  of,    10,    (fig.)    11;   56,    59 

Ludwig's  manometer,  self-registering,  10, 
(fig.)  ii 

— method  due  to,  of  measuring  pressure 
in  capillaries,  84 

— cited    on    possibilities    of    bleeding    an 

animal   into  its  own  veins,   16 
— vaso-motor   system   and   its   functions, 
4,   5 

Ludwig  and  Von  Prey's  modification  of 
Marey's  sphygmograph,  92 


252 


THERAPEUTICS    OF    THE    CIRCULATION 


Ludwig  and  Schmulewitsch,  experiment 
of,  on  secretion  of  bile  by  excised 
liver,  1 6 

Lumen  of  arterioles — lessening  of,  causes 
of,  and  risks  from,  101 

— lessened,  not  necessarily  indicated  by 
loud  systolic  murmurs,  122 

Lungs  of  frog,  effect  on,  of  heat  and 
cold — author's  experiments,  51,  (fig.) 
54 

Lungs,  functions  of,  interfered  with,  by 
disordered  circulation — -injurious  re- 
action on  the  heart,  131 

— mechanical  interference  with,  of  ab- 
dominal distension,  131,  138 

— pressure  in — point  at  which  stoppage 
of  pulse  occurs — Valsalva's  experi- 
ment— author's  tests  on  himself,  130 

Lymphatics,  the,   course  of,  96,  99 

Lymph,  circulation  of,  or  flow  of,  7,  8, 
in  and  round  heart,  96-8,  (figs.)  97, 
101,  102 

— effusion   of,   with   local   vascular  dilata- 
tion— ailments  due  to,    117 
— arrest  of,  by   digitalis,   153 

Lymph  hearts,  in  frogs,  9 

MACLAGAN,  PROF.  DOUGLAS,  experiments 
of  author  in  his  laboratory  under 
Gamgee,  163 

Macrophags,  normal  and  destructive  ac- 
tion of,  in  body,  explained  in  rela- 
tion to  senile  decay,  206-7 

Magendie's  view  on  cause  of  first  sound 
of  heart,  41 

Malarial  affection,  possible  slowing  of 
pulse  due  to,  186 

Malnutrition,  due  to  grief — case  illustrat- 
ing, 105 

Mammalian  circulation,  experiments  of 
Traube  (in  relation  to  digitalis),  146 

— heart,  see  Heart,  Mammalian 

Mammals,  action  in,  of  digitalis,  146,  147, 
149 

— double  action  on,  of  nicotine,   167 

— effects  on,  of  aconite,  (a)  small  doses, 
171;  (b)  large  doses,  171 

— and  frogs,  effects  on,  of  nicotine,   167-8 

"  Man  (or  men)  as  old  as  his  arteries," 
truth  of  saying,  99,  205 

- — blood-pressure   in,    60 

— normal   pulse-rate   in,    107 

Mania,  bradycardia  due  to,   109,  188 

Manometers,  see  also  kymographs,  sphyg- 
momanometers,  etc. 

standardization  of,  82  • 

— aneroid,  of  Gaertner,  portable  form  of 
his  tonometer,  76,  (fig.)  75 

— Burdon-Sanderson's,  recording — the  first 
in  England,  n 

— Pick's  spring  pattern,  60 — how  used, 
(figs.)  58,  59 

— Hales's — the  first,   10 

— Hurtle's,  60 

— Ludwig's  registering,   10,    (fig.)    u 

— Marey's  metallic,  81;  how  used,  (figs.) 
57,  70;  improved,  (fig.)  81 

combination  of,  with  Mosso's  plethys- 

mograph,  (fig.)  70 

— mercurial  see  Hales's,  Ludwig's,  and 
Poiseuille's 

— Poiseuille's,  10 

— Roy's,  60 

Marey  and  Kronecker,  discovery  by,  of 
refractory  period  of  the  heart,  33 

Marey's  apparatus  for  measuring  blood- 
pressure  in  digit,  71,  (fig.)  71 


Marey's   cardiograph,   86,   and   fig. 

investigations  with,    86-90,    (figs.)    87, 

88 

— haemodynamometer,    how    used,  (fig.)  55 

— metallic  manometer,  81;  how  used, 
(figs.)  57,  70:  improved,  (fig.)  8:; 
combination  of,  with  Mosso's  plethys- 
mograph,  (fig.)  70 

— sphygmographs,  13 — original,  modified 
by  Ludwig  and  Von  Prey — transmit- 
ting, 92,  (figs.)  92-3 

— tambours,  64,   (figs.)   58,  86,  93 

Martin's  modification  of  the  Riva-Rocci 
sphygmomanometer,  78-9 

Massage,  see  also  Arterial  Massage  and 
Self-massage 

— effects  of,   on  the  pulse,    102,  202 

— high  value  of,  in  treatment  of  venous 
stasis  by  complete  rest,  202 

— use  of,  in  cases  of  severe  valvular  dis- 
ease during  absolute  rest  treatment 
— high  value  of,  134  et  seq. — method 
and  results,  137-9 

Massage  and  diet,   141  et  seq. 

Massage  and  rest,   134  et  seq. 

Mastication,  thorough,  and  slow,  neces- 
sary in  cases  of  palpitation,  181,  182 

Mastoid  process,  application  over,  of 
leeches  to  relieve  headache,  177 

Meals,  precautions  as  to  nature  of,  es- 
sential in  angina  pectoris,  191 

— precautions  essential  after,  in  the  same, 
192 

— small  and  frequent,  in  treatment  of 
palpitation,  181-2 

Meat,  boiled,  saltless,  but  otherwise  fla- 
vored, in  diet  for  mitral  disease — 
aim  of,  204 

— butcher's,  given  sparingly  in  chronic 
myocarditis  (Schott),  201 

Meat-extracts,  cardiac  stimulants,  not  nu- 
trients, 145 

— of  the  purin  type  to  be  avoided  in 
angina  pectoris — why,  191 

Medicine,  poisons  used  in,  in  heart  com- 
plaints, 146-7 

Medulla  oblongata  (see  also  vagus  center 
in),  action  on,  of  digitalis,  149,  155 

(chief   center  of  nervous   system),   in 

relation  to  the  blood-pressure,   15 

disease  of,  or  injuries  to,  bradycardia 

due  to,   109,   1 88 

inhibitory   apparatus   in,    or   in   heart, 

excessive  action  of,   probable  cause 
of  slow  pulse,   186,   187 

Medusae,  comparison  between,  and  the 
heart — experiments  of  Romanes,  26 
et  seq. 

— compression  as  affecting  passage  of 
stimuli  in,  30 

— contractile  tissue,  (fig.)  28 — action  on, 
of  poisons,  30-1 

— described,  26-7 

— effect  on,  of  constant  and  successive 
stimuli,  29 

of  poisons    (Romanes),   29-31 

— rhythmic  movements  of,  dependent  on 
ganglia — as  affected  by  nicotine,  30 

Megrim,   see  Migraine 

Meibomius,  acquainted  with  the  indepen- 
dent pulsation  of  veins  (1668),  18, 
note 

Melancholia,   bradycardia   due   to,  109,  188 

Meningitis,    relief    in,    by    application    of 

leeches  over  mastoid   process,    177 
— simple    or    tubercular,    bradycardia    oc- 
curring in,   187-8 


INDEX  253 

Mental     activity,     effect     on,     of     tobacco-  Mitral    regurgitation,   organic  —  causes   and 

smoking,   169  consequences,    127 

-  effect     produced    by,     on    volume     of  -  slight,    frequency    of  —  treatment,    197 

arm,   114  -  with    venous    stasis,    etc.,    202  —  treat- 

—  deterioration,   a  result  of  cerebral   hem-  ment,   197 

orrhage,  206-7  -  systolic    murmur    indicative    of  —  con- 

Mercurial    manometers,    see   Hales'  s,    Lud-  ditions  presenting,    126 

wig's,    and   Poiseuille's  Mitral  stenosis,   a  cause  of  venous  stasis, 

—  purgatives,   occasional   use  of,   beneficial  202 

in    cases    of    senile    rise    of    pressure,  —  surgical     treatment     of  —  its    possibili- 

208  ties,   205,   and  note 

—  in     treatment     of     angina     pectoris  —  Mitral    valves,    incompetence  of,  see  Mitral 

how    reinforced  —  reason    for,    192  Incompetence,  supra 

—  in    treatment    of    toxin-caused    brady-  —  less   liable  to   incompetency  than   the 

cardia,    188  tricuspid,  44 

Mercurials,  action  of,  not  properly  under-  Montgomery,    Lord,    case    of  —  proof    that 

stood  —  effects   of,   valuable,    203  external    pressure    is   not    felt   by   the 

Mercury,    danger   of,    in    albuminuria,    ex-  heart,    120 

aggerated  —  action    of,    on    circulation,  Morphine,     remedy     par     excellence     for 

208  sleeplessness   in   cardiac   disease  —  how 

—  in   kymographs,  oscillations   of,  57,  (fig.)  given,     194  —  doses  —  danger    in     with- 

57;   how  avoided,  59  holding,    195 

Metchnikoff,   cited  on  senile  decay  as  due  —  sometimes    necessary   to    relieve    neural- 

.   to    destructive    action    of    macrophags,  gic     element     in     severe     anginal     at- 

206-7  tacks  —  how  given,    191 

Methylxanthine   and   other  purin  bodies  —  Mosso's  ergograph,    (fig.)    136 

use  of,    145  —  experiment    on    size    of    arm,    as   condi- 

Meyer,   A.   B.,  see  Brunton  and  Meyer  tioned  by  hard  thinking,    114 

Microphags,    function   of,   206-7  —  plethysmograph,     69;     combination     of, 

Micturition,   risk  of   fatal  syncope   during,  with     Marey's     metallic     manometer, 

in  cases  of  overuse  of  digitalis  —  why,  (fig-)  70 

163  —  sphygmomanometer,    71,    72 

Mid-sternum,   pain  of  angina   felt   at,    189  Motor  function  of  arteries,  4 

Migraine,    megrim,   or   sick    headache,  Mouth,    administration   of  opium   by,    why 

—  pain  in,  causes  of  —  modes  of  relief,   119  less    advantageous    than    by    rectum, 

-  nature    of  —  similar    to    that    of    colic,  I94~5 

119-20  Movements    of    the    heart,    views    on,    of 

—  pathology    of,    views    of    Du    Bois    Rey-  Gaskell,  and  of  Engelmann,    18 

mond,    and    others  —  author's   personal  Miiller,     Johannes,     acquainted     with    the 

observations   and    conclusions,    119-20  independent        pulsation       of       veins 

Milk  —  components     in,     why     valuable     in  (1835),    18,   note 

mitral  disease,   204  Murder    (constructive)    by    a   curate  —  jilt- 

-  —  given     freely     in     chronic     myocarditis  ing     followed     by     grief,     consequent 

(Schott),  201  malnutrition,   phthisis   and   death,    105 

Milk    diet    and    chloride-free    food  —  cases  Murrell,    Dr.,    anticipation    by,    of    author 

for  which  adapted,   204  in   use   of  nitroglycerine  —  why,    165 

-  useful  in  sleeplessness  in  cardiac  dis-  Muscle,    elongation   of(?),    45,    (fig.)    46 

ease,  193  —  in  differentiated  protoplasm,  as  affected 

Milk  and  potatoes  —  fatal  meal  of  —  why  by  stimuli,  25 

so,  140  Muscle(s),  see  also  Cardiac  Muscles, 

Mitral  disease,  allowance  of  fluid  in,  in  Fasciae,  and  tinder  Names 

Nauheim  treatment,   201  —  accessory,   of   circulation,    7,    131 

-  milk    diet    and    chloride-free    food    in,  —  circulation    in,     effect    on,     of    absolute 

with     rest,     massage,     and     digitalis  rest   treatment,    135  —  influence   on,   of 

and    blue    pill  —  improvement    often  rest   and   massage,    138 

rapid,  204  Muscular    area,     influence    of,    on    blood- 

-  treatment      of      mitral      incompetence  pressure,    1  5 

from    aortic    regurgitation    as    for,  —  contraction    as    affecting   flow    of   blood, 

196-7  6,   and  of  lymph,  9,    (figs.)   8,  9 

Mitral    incompetence,    engorged    condition  —  induced    by    small    doses    of    caffeine, 

of    right    side    of    heart    due    to,    re-  145 

lieved  by  blood-letting,    177  Muscular   fiber  (s)    of    arteries   and    heart, 

-  how    induced    by    regurgitation—  con-  contraction    of,    caused    by    digitalis- 

sequences—  treatment,    196-7  how   effected,    149-50 


when 


° 


—  (functional)  —  causes       and       conse-  -  of  heart,  action  of  purin  bodies  prob- 

quences,    126  ab]v    more    especially    on,     and    on 

—shortness     of     breath     in—  treatment,  secreting  cells   in   kidneys,    161-2 

,....       .  J97  -  as    affected    by    stages   of   action    of 

Mitral      obstruction  —  causes     and      conse-  digitalis,    157,    159 

quences,    127-8  -  slight  action  on,   of  strychnine,    161 

—  with    regurgitation  —  cardiac    dyspnoea  —  involuntary,     less     capable     of,     with- 

associated    with,    128-9  standing     constant     than     intermit- 

Mitral     regurgitation  —  causes     and    conse-  tent    strain  —  proof    seen    in    mitral 

quences,    126,    201  obstruction,   128 


254 


THERAPEUTICS    OF    THE    CIRCULATION 


Muscular  fibers — round  auriculo-ventricu- 
lar  orifice,  action  of.  in  normal  con- 
traction of  the  ventricle  (Ludwig), 
125 — aid  given  by,  to  the  valves,  40, 
(figs.)  39 

Muscular  inadequacy  in  walking,  see 
Claudication 

— Movements  acting  as  subsidiary  heart,  9 

— poisoning,  caused  by  large  doses  of 
caffeine,  145 

— spasm,  high  blood-pressure  partly  due 
to,  in  cases  of  gouty  kidney  disease, 
101 

Muscular  tissue  (generally),  effect  on,  of 
heat  and  'cold,  50,  (figs.) 

(structure)    of  the   heart,  as   affected 

by  the  toxins  of  diseases,    100,    105 
— effect  on,   of  digitalis,    147 

effect    on,    of    gradual    blocking    of 

coronary  arteries.    100 
— fatty     or     fibrous     degeneration     of 
(q.    r.),    100 — effects   of,   on   car- 
diac action,    105 

Muscular  walls  (contractile)  of  arterioles, 
effect  on,  of  digitalis,  147 

Muscular  and  nervous  conduction  in  the 
heart — experiments  of  Brunton  and 
Cash,  33  et  seq.,  112,  (figs.)  35 

Musculi  papillares,  irregular  action  of, 
causing  mitral  regurgitation,  126 

Mustard  poultice,  redness  from,  imme- 
diate and  after — probable  causes,  47, 
(fig.)  48 

Mustard-and-water  emetic  to  cut  short 
attack  of  paroxysmal  tachycardia, 
184-5 

Myocarditis,  chronic,  diet  in,  according 
to  Dr.  Schott,  201 

Myxoedema,  effects  of  protracted  treat- 
ment of,  with  thyroid  gland  extract 
(by  mouth),  107 

NAPOLEON  the  Great,  slow  pulse  of,  108, 
186 

Narcotics,  to  relieve  neuralgic  element  in 
angina  attacks,  191 

— to  relieve  sleeplessness  in  cardiac  dis- 
ease, 193-5 

Nauheim  treatment — cases  to  which  ap- 
plicable— methods,  199  et  seq.,  (figs.) 
199 

Nausea,  early  symptom  of  toxic  action  of 
digitalis,  155 

Neck  and  head,  arteries  of,  as  affected  in 
migraine — author's  view,  119 

Nephritis,  acute,  wet  cupping  over  kid- 
neys for,  177 

• — chronic  interstitial,  bradycardia  in- 
duced by — how,  1 88 

— rise  of  blood-pressure  in,  risks 

from,  49-51 

Nerium  oleander,  action  of — not  used 
medicinally,  146 

Nerve  centers,  reflex  excitability  of,  in- 
creased by  strychnine,  161 

Nerve-fiber  in  differentiated  protoplasm, 
as  affected  by  stimuli,  25 

Nerves,  see  also   under  Names 

— arterial  massage  of,   in  health,   134 

— irritation  of — severe  pain  from — effect 
of,  on  heart,  113 

— soothed  by   tobacco-smoking,    169 

Nerves  of  arterioje-muscular  walls,  effect 
on,  of  digitalis,  147 

— of  arterioles  and  veins,  observations  on, 
of  Brunton  and  Schweigger-Seidel,  45 


Nerves  of  opposing  action  in  heart,  and 
in  vessels,  45 

Nerves  and  muscles  of  circulation,  in- 
creased action  of  all,  first  stage  of 
action  of  digitalis,  159 

Nervi  erigentes,  dilatation  by,  how  in- 
duced, 46 

Nervous  centers,  effects  on,  of  digitalis 
poisoning,  149,  154 

— depression,  causes  and  consequences, 
102,  104 

— fibrils,  found  by  author  on  surface  of 
muscular  layer  of  arterioles,  45 

- — fluttering  of  the  heart,  quieting  effect 
on,  of  very  small  doses  of  aconite, 
172 

— irritability  in  bradycardia  due  to  reflex 
inhibition  from  stomach  —  treatment 
to  soothe.  1 88,  and  note 

in  Graves's  disease — drugs  quieting, 

183-4 

— people,    pulse-rate   in,    107 

— stimulants,  derived  from  dietetic  uses 
of  plants  producing  caffeine,  etc., 
161-2 

— supply,  altered,  a  cause  of  fatty  degen- 
eration of  the  heart,  105 

Nervous  system,  as  affected  by  digitalis, 
149.  154 

control  of,  over  the  heart  and  blood- 
pressure,  how  exerted,  15;  extent 
of,  45 — how  affected  by  digitalis, 
159 

share  of,  in  angio-neurotic  oedema — 

how  evidenced,  117-8 

share  of,  in.  cardiac  rhythm — author's 

view  on,  32,  33,  and  note,  (figs.) 
35 — possible  cause  of  tachycardia, 

I  I  1-2 

Nervous  wave  in   medusa,   29 

Nervous  and  muscular  conduction  in  the 
heart — experiments  of  Brunton  and 
Cash,  32,  33,  and  note,  (figs.)  35,  112 

Neuralgic  element  in  severe  anginal  at- 
tacks— how  best  relieved,  191 

Neuritis,  alcoholic,  paralysis  of  vagi  due 
to — consequent  rapidity  of  pulse,  107 

—of  the  vagus,  effects  of,  in  convales- 
cence from  diphtheria,  186 

Neuro-muscular  bundle  described  by  Kent 
and  His,  nature  and  apparent  func- 
tions, 35,  note 

Nicotine,  action  of,  on  circulation,  160 — 
double  nature  of,  167 

on  frog's  heart,   167-8 

on   ganglionic   structures — medusse,  30 

Nightmare,  characteristic,  caused  by  sleep- 
ing on  the  back — what  it  indicates,  180 

Nitrate  of  potash,  with  nitrite  of  so-  • 
dium,  beneficial  in  high  tension — 
dose,  208 — how  supplemented,  208-9 

Nitrites,  see  Amyl  Nitrite  and  Sodium 
Nitrite;  see  also  Vaso-dilators 

— amplitude  of  pulse,  how  increased  by, 
1 02 

— effect  of,   on   angina  pectoris,    189,    191 

on  circulation,  pulmonary  and  gen- 
eral, 193 

— reduction  by,  of  blood-pressure  in 
gouty  kidney  cases,  101 

Nitrobutyl,  etc.,  action  of,  in  relief  of 
angina  pectoris,  189 

Nitro-erythrol,  beneficial  in  cases  of  high 
tension — dose,  208 

— preventive  action  of,  in  persons  other- 
wise liable  to  angina  pectoris — how 
employed,  192 


INDEX 


255 


Nitroglycerine,  165;  action  of,  in  angina 
pectoris— how  administered  —  special 
advantage  of — tablet  form  to  be  nib- 
bled— quantity  safe — sole  bad  effect, 
191 

— beneficial  in  cases  of  high  tension — 
dose,  208 

— overdoses  of,  headache  the  sole  ill- 
effect  from,  191 

Nitro-mannitol,   uses  of,    166 

Nitrogenous  diet,  ill-effects  of,  in  age — 
Haig  cited  on,  207-8 

Nodular  form  of  interference  with  ar- 
terial blood  supply  — •  consequences, 
101 

Numbness  and  tingling  caused  by  small 
quantities  of  aconite  applied  to 
tongue,  171 

Nutrients,  cardiac,  see  Blood  and  Cardiac 
Tonics 

Nutrition  of  blood-vessels,  effect  on,  of 
feebleness  of  the  heart,  101 

— failing,  from  disease — fatty  degenera- 
tion of  the  heart  found  in,  99 

— of  heart,  94-6 — how  benefited  by  digi- 
talis, 150  et  seq. 

— general — how  improved  by  action  of 
digitalis,  154 

Nutritive  action  of  cardiac  tonics,  98, 
144,  145,  150,  154 

Nux  yomica — beneficial  in  cases  of  pal- 
pitation associated  with  debility,  183 

in   treatment   of   bradycardia,    188 

OBLITERATION  of  blood-vessels  —  causes 
and  consequences,  115-6 

Obstruction,  aortic,  to  be  distinguished 
from  stenosis — why,  122 

CEdema,    action   on,   of  digitalis,    152-4 

of  rest  and  massage,    138 

— angio-neurotic,  characteristics  of  — 
pathology  not  made  out — author's 
view,  1 1 7-8 

—of  feet  and  ankles,  first  indication  of 
venous  engorgement — why — how  re- 
lievable,  129 

— of  legs  or  scrotum — tapping  for — meth- 
od, 204 

— universal,  induced  by  injection  of  anti- 
streptococcic  serum,  118 

— in  relation  to  venous  obstruction  and 
to  vaso-motor  nerves — Ranvier's  ex- 
periment, 1 53 

Oertel's  treatment — principles  and  meth- 
ods, 20 1-2 — cases  to  which  applicable, 
193,  201 

Old  people,   see   also   Elderly  and   Senile 

— arterial  changes  in,  89,  99,  100-1,  116, 
205,  (figs.)  88,  98 

aortic  valves   and   aorta   in,    122 

— brown    atrophy  in,   causes  of,    100 

— causes  of  death   most  frequent  in,  207 

— destructive  action  in,  of  macrophags 
(Metchnikoff),  206-7 

— effect  on   circulation   of.   of  grief,    104 

— fatty  degeneration  of  the  heart  found 
in,  99 

— rise  of  blood-pressure  in — risks  of,  in 
combination  with  atheromatous  ar- 
teries, 205 

Oliver,  ammonium  hippurate  recom- 
mended by,  in  cases  of  high  tension, 
208 

— arteriometer  of,   83 

— sphygmomanometer  of,   68,    (fig.)   67 

Operations,  formerly  performed  in  a  state 
of  syncope,  115 


Opium,  remedy  par  excellence  for  sleep- 
lessness in  cardiac  disease  —  how 
given — doses,  193-4;  danger  in  with- 
holding, 195 

— use  and  abuse  of — parallel  in  massage, 
135 

Oppression,  intense  —  sensation  of,  fre- 
quent in  angina  pectoris — probable 
cause — author's  deduction  from  sim- 
ilar sensation  due  to  grief  in  own 
case,  121 

Organs,  functions  of,  disturbed  by  disor- 
dered circulation,  rendering  that  dis- 
order worse — how,  131 

— to  which  the  vagus  nerve  gives  branches, 
104 

Oscillations  in  kymographs,  how  avoided, 
60 

Ossification  of  arteries — consequences,     116 

— of  coronary  arteries,  angina  pectoris 
due  to — observations  on,  of  Jenner 
and  Parry,  cited  by  Brodie,  1 16 

Oubain  (Acocanthera),  action  of- — -not 
used  in  medicine,  146 

Overdoses  of  nitroglycerine  or  amyl  ni- 
trite, headache  sole  ill-effect  from, 
191 

Oxidation,  effect  on,  of  digitalin  and 
caffeine,  Pickering  on,  147-8 

• — effect  on,  of  other  drugs,  condition  of 
embryonic  heart  induced  by,  148 

• — relation   to,    of   cardiac    tonics,    148 

— of  waste  products,  effected  by  com- 
bined rest  and  massage,  138 

Oxygen,  inhalation  of,  in  cardiac  asthma, 
remarkably  good  effect  of,  193 

in  treatment  of  venous  stasis,  benefit 

of — possibly  in  part  mechanical,  203 

PAGE,  MR.,  see  Sanderson,  Sir  J.  Burdon-, 

and   Page 

Pain  of  angina  pectoris — causes,   116,   126 
— author's   view,    122,    and    note,    189 
— location   of,    189 

• relief   of,    by    general    bleeding,    175, 

177 

relation    between,    and    tension,     122, 

and   note 

— severity  of,   121 

• — intense,    power    of    the    heart    to    origi- 
nate,   121 
- — of     migraine — causes — mode     of     relief, 

1 20 — nature  of,    120 

— severe  effects  of,  contraction  of  abdom- 
inal vessels  and  maintenance  of  cir- 
culation, 113 

— heart-stoppages  sometimes  due  to,  113 
Palpitation    of    the    heart    absent    (gener- 
ally)   in   hypertrophied   heart,    112 
— associated     with     debility,      112;     treat- 
ment,  1 83 
— causation     of,    obscure — author's    view, 

112 

disturbance    in    pelvic    organs  —  cau- 
tion,   183 

excitement,    177 

failing  compensation,    124-5 

faulty  diet,    179 

Graves's  disease,  see   that  head 

lying    on    back    or    left    side,    in    bed 

112,   i  So 

— over-smoking,   170 

— stomach-distension      from      flatulence, 
i  go 

weakness  of  the   heart  itself,    183 

• — characteristics  of,    112  et  seq. 
• — effect  on,   of  position,    112-3,    180 


256 


THERAPEUTICS    OF    THE    CIRCULATION 


Palpitation  of  heart,  induced  by  ammonia 

liniment   applied   over   heart,    178 
— mechanism  of — author's  view,    112 
— position  in  sleen  as  affecting,   112-3,  l%° 
— quieting    of,    by    local    external    means, 

179. 
— sometimes     subjective     sensation     only, 

I  12 

— tendency   to,    increased   by   pressure   of 

corsets  or  belts,    141 
— treatment   of — 
— diet.   178-81 

drugs,    1 80- 1,    183 

exercise,  open-air,    183 

massage,  ib. 

regimen,   181-2 

— \\  eir-Mitchell  methods  in  severe  cases, 

183 

Paraldehyde,     in    treatment    of    sleepless- 
ness in  cardiac  disease— niose,    193 
Paralysis,   see  also  Hemiplegia  and  Paresis 
— after    convulsions    caused    by    nicotine, 

167-8 
— after    diphtheria — causes — consequences, 

187 
— general,    of  the   insane,   bradvcardia   in, 

109 

- — of  inhibitory  apparatus  in  the  heart,,  by 
nicotine — effect    on    pulse- rate,     167-8 
— local,    resulting   from   rupture   of  blood- 
vessel in  brain,   206 

— secondary  to  disease  of  cerebral  ves- 
sels, 206 — how  preventable,  by  treat- 
ment of  senile  conditions  of  vessels, 
208 

— of  vagus  and  other  nerve,  caused  by 
diphtheria  toxin,  105,  107,  187;  and 
after  alcoholic  neuritis,  107 — -pulse- 
rate  in,  107 

Paresis,   general,    bradycardia   in,    187 
Parkes,  value  of  beef-tea,   etc.,    as  stimu- 
lants shown  by,  in  Ashanti  campaign, 
145,  and  note 
Paroxysmal  tachycardia,   see  Tachycardia, 

Paroxysmal 

Parry.  Dr.,  observations  of,  cited  by 
Brodie  on"  cause  of  angina  pectoris, 
116 

Pastry,  to  be   avoided  in  palpitation,   181 
Pathology    of    angio-neurotic    oedema,    not 

understood — author's   view,    118 
Pathology  of  the   circulation, 

effect   of  altered   quality  of  blood,   99 

— of  blocking  (however  caused)  of 
coronary  arteries,  96,  100,  116, 
192 

— of  feebleness  of  the  heart  on  nutri- 
tion of  blood-vessels,  102 

causes  of, 

— fatty   degeneration    (q.   v.),  104 
— nervous   depression,    104 
— exophthalmic  goitre,    107 
— pulse-rate — factors    conditioning,     105 
— normal    rate    in    men,    107— rate 
in  fevers,    107 
Pathology     of     syncope,     not     thoroughly 

made  out,   114 
Pelvic  organs,   disturbances  in,  palpitation 

often   associated   with — caution,    183 
Peppermint    water,    useful    in    palpitation 

from    flatulence,    180 
Pepsin,   etc.,  use  of,   in  certain   forms  of 

tachycardia,    185 

Pericardium,    Briicke's   simile   for,    97 
Pericarditis,     relief    in,     from    application 
of  leeches  over  cardiac  area,   177 


Perihepatitis,     with     hepatitis,     relief    in, 

from     application     of     leeches     over 

liver,   177 

Peripheral   contraction,   with  central   dila- 
tation   of   arteries    of    head   and    neck 

-^-cause     of     migraine,     in      author's 

view,   1 1 9-20 

— ganglia — dilatation    connected    with,    45 
— resistance,     increase     of,     in     arterioles, 

dangers  from,    101 
Peristaltic    action    and    normal    beats    of 

frog's  heart    alternating,   as   effect   of 

aconite,    171 

— and  motor  action  of  the   arteries,   5 
Peritoneal  fluid,   effect  on,   of  movements 

of  respiration,  9 
Permanent    pressure,    local,    in    relief    of 

palpitation,    178 

— relief   of   palpitation — essentials,    178-9 
Phagocytes — two  classes  of — functions  of, 

206-7 
Pharmacology     (.see    also    Treatment)    of 

the  circulation,    i 
Pharyngitis,    benefit    in,    from    cold-water 

compress — how    produced,    175 
— chronic,   induced  by  over-smoking,    170 
Pharynx,    nerves    going    to,    paralysis    of, 

due  to  diphtheria  toxin,   105 
Pheasant's    eye     (.Adonis    vernalis),    uses 

of,   146 
Phosphorus,     fatty     degeneration     of     the 

heart   found    after   administration   of, 

100 
Phosphates,    use    of,    in    Graves's    disease 

(Kocher),    183-4,   and  note 
Phrynin,    source   and   action  of — story  of, 

146-7 
Phthisis,     abnormally    low     blood-pressure 

as  precursor  of — case  in  point,    105 
— induced  by  malnutrition  due  to  grief — 

case  of,   105 

Physiology   of   the   circulation,    i 
— accessory   muscles  of  circulation,    7 
— arterial    tension,    or    blood-pressure    (g. 

v.),  10 

arteries   and,    15 

— regulation   of,    13-4 

depressor   nerves,    17-8 

- — — influence    of    muscular    area,    15-6 

— influence    of    splanchnic    area,    16-7 
— arteries,  4 

— motor    and    peristaltic    action    of,    5 
• — capillaries  and  veins,   5 
— fasciae,   action  of,   6,    131 
— heart,   chief   function   of,   3 

movements   of — views  of   Gaskell,    18 

— refractory  period  of,  4,  33 

sleep  of,  3 

— valves  of,   39-40 
— heart  of  the  frog,    19 
movements    of — investigation    of,    22 

— comparison     between     and     a     me- 
dusa— experiments    of     Romanes, 
26-7 
transmission  of  stimuli  in,  31-2 

—  nervous    and    muscular    conduction 
in,    32 — experiments    of    Brunton 
and  Cash,  33  et  seq. 
— independent  pulsation  of  veins,   18 
- — lymph,   flow   of,    9 
Pickering's    (J.    W.),   observations   on   the 

action    of   cardiac    tonics   on    the    em- 
bryonic  heart,    148 
Picoline    bases    in    smoking-tobacco    in    its 

various   forms,    168 

Piegu's    instrument    for    estimating    blood- 
pressure,   71 


INDEX 


257 


Pig-tail  tobacco,  demerits  of — heart-beat 
with,  170 

Pill  of  digitalis  powdered,  powdered 
squill,  and  blue  pill — one  grain  of 
each— how  modified  at  St.  Bartholo- 
mew's Hospital  and  elsewhere,  203 

Pipe-smoking,  and  cigar-smoking,  better, 
or  less  bad  than  cigarette-smoking, 
169 

Plant-poisons,  similar  in  action  to  digi- 
talis—names, 146 

Plants  containing  caffeine,  etc.,  dietetic 
uses  of,  medicinal  action  (probable) 
of,  161-2 

Plasmon,   in  diet  for  mitral  disease,   204 

— recommended  by  Schott  in  chronic 
myocarditis,  201 

Plasters  over  heart,  quieting  effect  of,  on 
palpitation — best  kind,  178 

Plethysmograph  of  Hallion  and  Comte, 
(fig.)  73 

— Mosso's,  (Jig.)  69 

combination  of,  with   Marey's  metallic 

manometer,    (fig.)   70 

— demonstration  by,  of  reduced  size  of 
limbs,  during  brain  activity,  114 

Pleural  effusion,  insidious  and  serious 
character  of — serious  in  valvular  dis- 
ease, 139 

removed  by  rest  and  massage,   139 

— tapping  for,   204 

— fluid  effect  on,  of  movements  of  respi- 
ration, 9 

Pleurisy,  severe,  immense  relief  afforded 
in,  by  leeches  to  side,  177 

Pliny,  aware  why  drinking  bull's  blood 
caused  death,  141,  note 

Pneumogastric  nerve,  method  of  action 
of,  on  intestines,  etc.,  104,  note 

Pneumonia,   heart-weakness   due  to,   caus- 
ing bradycardia,   108,   186 

Points  at  which  first  and  second  sounds 
of  heart  are  best  heard,  42 

Poiseuille's   manometer,    10,    (fig.)    ll 

Poisoning  by  bile  acids  in  jaundice — bra- 
dycardia due  to — how  induced,  io'9 

— by   digitalis — effects  of,   on — 
— apex-beat   in   animals,    112 
— nervous  centers,   149,  155 

pulse — causing    irregularity,  in  man, 

no 

Poisons  causing  bradycardia,    108-9,    187 

— effect  of,  on  medusae,  Romanes'  experi- 
ments, 29-30 

— giving  rise  to  fatty  degeneration  of  the 
heart,  100 

— vegetable,  similar  in  action  to  digitalis 
— names,  146 

Position,  see  also  Upright,  Recumbent, 
Sitting,  Stooping  Position 

— in  bed,  in  relation  to  palpitation,  112, 
179-80 

— best   for   averting  faintness,    115 

for   restoring   fainting  persons,    115 

— change  of,  from  recumbent  to  erect,  in 
rising  to  micturate — effect  of,  on 
blood-pressure — fatal  syncope  due  to, 
163 

— in  relation  to  blood-pressure  in  the 
brain,  i i 5 

— for  severe  cases  of  valvular  disease, 
132-3 

recumbent   best,    132 — beds   for,    133 

sitting,     reasons     for     adopting — pre- 
cautions,  133-4 

Potain-Gaertner  combined  apparatus  for 
measuring  blood-pressure,  (fig.)  76 

18 


Potain's  sphygmomanometer,  67,  79,  (fig.) 
66— fallacies  in  applying,  68 

author's  use  of,   (fig.)   80 

Potash,  nitrate  of,  with  nitrite  of  sodium, 
beneficial  in  high  tension,  208 — how 
supplemented,  208 

Potassium,  bitartrate  of — addition  of,  to 
compound  jalap  powder  —  advantage 
of,  203 

• — bromide  of,  in  treatment  of  bradycar- 
dia due  to  reflex  inhibition  from 
stomach,  188 

— in  Graves's  disease — effects  of,   184 

Potatoes  and  milk — fatal  meal  of — why 
so,  140 

Poultice,  mustard,  redness  after — prob- 
able causes,  47,  (fig.)  48 

— warm,  over  heart,  stimulating  effect' of, 
178 

Power,  Mr.,  see  Brunton  and  Power 

Powell,  Sir  Douglas,  cited  on  heart's 
great  dependence  on  due  pulmonary 
aeration,  94 

Pressure,  see  Blood-pressure,  Diastolic, 
and  Systolic  Pressure 

— on,  or  hi  brain,  bradycardia  caused  by 
— how,  109,  187-8 

— hand,  or  permanent,  quieting  effect  of, 
on  palpitation,  178 

— from  without,  on  hollow  muscular  or- 
gans— not  pain-producing,  120 

not  felt  by  the  heart — historic  in- 
stance, 1 20 

— on  vagus,  discomfort  due  to — Czermak's 
personal  experience,  121,  and  note 

Prolongation  of  life,  suggestions  for,  by 
attention  to  arterial  conditions,  205, 
209 

Proteids  in  food,  benefit  of  reducing,  in 
cases  of  senile  rise  of  pressure,  208 

Protoplasm,  living,  in  relation  to  con- 
tractility under  stimulus,  (a)  undif- 
ferentiated,  24-5;  (b)  differentiated,  25 

Pulmonary  aeration,  great  importance  of 
proper,  to  the  heart  (Powell),  94 

— affections,  engorged  condition  of  right 
side  of  heart  due  to,  relieved  by 
blood-letting,  177 

— artery,   relative  resistance  of,  44 

right — weakness  of,  from  atheroma — 

consequences,  130 

— capillaries,  effect  on,  of  heat  and  cold, 

Si.    (fig-)    54 

giving  way  of,  in  mitral  obstruction 

cause  and  consequence,  128 

Pulmonary  circulation,  hieh  pressure,  ab- 
normal in,  causing  bradycardia — how, 

T  QQ 
loo 

impeded,  the  danger  in  mitral  incom- 
petence from  aortic  regurgitation 
— treatment,  196-7 

less  affected  by  nitrites  than  general 

circulation,  193 

— engorgement,  cause  of,   126 

Pulmonary  veins,  absence  of  valves  in, 
127 

blood-pressure  in,  in  mitral  regurgi- 
tation, 127 

contractile  power  of,  and  independent 

pulsation  in,  rediscovered  by  Fayrer 
and  Brunton,  18,  44,  127,  128,  note 

pressure  on,  in  mitral  obstruction — 

possible  stimuli  excited  by,  and 
further  interference  with  heart- 
rhythm,  128,  note 

Pulsation,  arterial,  coincident  with  respi- 
ration, 46-7 


2S8 


THERAPEUTICS    OF   THE    CIRCULATION 


Pulsation,  arterial,  observable  in  persons 
with  aortic  regurgitation  —  coinci- 
dence of  the  three  rhythms  in,  47 

— cardiac — possible    part    cause   of,    171 

— of   embryonic   heart,    25 

— of  femoral  artery,  increased  by  immer- 
sion of  feet  in  hot  water,  175 

— of  frog's  heart,  rate  and  character  of, 
as  affected  by  digitalis,  147 

—independent,  of  veins,  18,  and  notes, 
44,  128 

Pulse,  see  also  Bradycardia  and  Tachy- 
cardia 

- — aortic,  tracings  of,  with  Marey's  car- 
diograph, 90,  (figs.)  88 

— arterial   pulsation   coincident   with,   46-7 

— author's  own,  his  own  observations  on, 
163 

— bigeminal — nature — instance,    189 

— carotid,  when  to  be  used  to  fix  time 
of  cardiac  murmurs,  92 

• — condition  of,  in  bradycardia,  108,  109, 
iii 

in  paroxysmal  tachycardia,   108,   109 

— effect  on,  of  aconite  in  large  doses,   171 

of  digitalis-poisoning  —  three  stages, 

1 88 

of  massage  and  exercises  described, 

202,  (fig.)  197 

— feebleness  of,  effect  of,  on  nerves, 
I34-S 

— intermittent,  varieties  of,   109-11 

causes  uncertain — author's  own  view, 

ii i-i2 

— irregularity  or  intermittence  of — forms 
of  —  causes,  109-12  —  persistence  — 
treatment — instances,  188-9 

greater  frequency  of,  in  mitral,  than 

any  other  form  of  cardiac  disease 
— why,  126,  128 

— (man's),  feeling  of,  methods  and  aim 
in,  60 

— of  Napoleon  I.,  slowness  of,   108,   186 

—opposite  effects  on,  of  sequelae  of  diph- 
theria, 187 

—quickened,  arterial  tension,  and  pain  of 
angina  pectoris — relation  between — 
cases  illustrating,  121,  and  note 

— -radial,  when  not  to  be  used  to  fix  time 
of  cardiac  murmurs,  92 

— rapid,  characteristic  of  tachycardia — • 
treatment,  184-5 

drugs  to    reduce,   and  bleeding,    166 

or  quickened — in  attacks  of  angina 

pectoris,  121,  and  note 

— rapidity  of,  extreme,  indicating  paral- 
ysis of  vagus,  105,  106-7 

— recurrent,  how  obstructed  in  measur- 
ing human  blood-pressure,  62,  67, 
(fig.)  66 

— senile,  analogy  of,  to  ventricular  beat, 
(fig.)  88 

— slow,  in  bradycardia,  characteristics  of, 
1 08,  1 86 

naturally  so,   instances  of,    108,    186 

— slowing  of,  by  digitalis,  how  effected, 
149 

by  general  bleeding,    166 

— slowness  of,  abnormal,  after  toxic  doses 
of  digitalis,  155 

— stoppage  of,  when  pressure  within 
lungs  reaches  certain  point — Val- 
salva's  experiment — author's  tests  of, 
130 

Pulse-beats  (see  also  Heart-beats),  alter- 
nately weak  and  strong  in  brady- 
cardia,  108 


Pulse-rate,  as  affected  by 
— exophthalmic   goitre — process,    107 

— — nicotine    acting    on    vagus    center    in 
medulla,   167 

— in  bradycardia  and  tachycardia,  dis- 
turbed— rhythm  unaltered,  109-10 

• — -factors  on  which  dependent,  heat,  cold, 
106-7;  poisons,  107 

— in  fevers,    107 

— in  mammals  and  frogs,  action  on,  of 
nicotine,  167 

— in   nervous  people,    107 

— normal,  in  men,   107 

— rapid,   consequences  of,   and  treatment, 

3~4 

— when  vagi  are  paralyzed,   105-7,   J87 

Pulse-rhythm  in  bradycardia  and  tachy- 
cardia remaining  regular — rate  dis- 
turbed, 109-10 

Pulse-wave,  amplitude  of,  external  and 
internal  means  for  securing — proc- 
esses involved,  102 

— nature  of,  instruments  for  ascertaining, 
84  et  seq. 

— retardation  of,  92,   (fig.)  91 

— smallness  or  feebleness  of,  effect  of, 
however  caused,  102 

fatty    degeneration    (q.    r.)    as    cause 

of,   104 
nervous   depression    as   cause   of,    104 

"  Pulris  nrirabilis,"  for  functional  irrita- 
tion of  the  heart  —  prescription  — 
notes  on,  181,  183 

Puncture  (see  also  Tapping),  for  oedema 
of  legs — methods,  204 

Purgation,  free,  in  treatment  of  toxin- 
caused  bradycardia- — class  of  purga- 
tives preferable,  188 

Purgatives,  see  also  Aperients,  Mercurial 
Purgatives,  and  Saline  Purgatives 

- — best  adapted  for  treatment  of  toxin- 
caused  bradycardia,  188 

— in  treatment  of  cardiac  diseases — why 
essential,  203 

Purin  bodies,  enumeration  of,  and  uses, 
145,  161-2 

Purin-type  of  meat-extracts  to  be  avoided 
in  angina  pectoris — why,  191 

Purkinje,   fibers  described,   35,   note 

Pye,   Mr.,   see  Brunton  and   Pye 

Pyridine  bases  in  tobacco,  in  its  various 
smoking  forms,  168 

QUALITY  of  blood,   altered,   effect  of,   100 
Quickening,    sudden,    of   pulse,    with   sud- 
den   return   to    the   normal,   see   Par- 
oxysmal  tachycardia 

RABBITS'  hearts,  fatty  degeneration  found 
in,  on  section  of  vagi  (Wassilieff), 

i°5 

Radial  artery,  decreased  pulsation  in, 
caused  by  cold  bandage  to  middle  of 
arm,  175 

effect  on,  of  massage  and  exercises, 

(fig-)  197.  201 

tension  in — effect  on,  of  inhalation  of 

oxygen  in  cardiac  asthma,  193 

— pulse,  coincidence  of,  with  cardiac  dias- 
tole— when  found,  92 

Ranvier,  M.,  figures  of  parts  of  frog's 
heart  due  to,  24,  25,  37 

Rapid  action  of  heart,  persistent,  after 
excessive  exercise — treatment,  184 — 
symptom  in  paroxysmal  tachycardia, 
184 


INDEX 


259 


Rapidity    of    contraction,    causes    of    loud 

first   heart  sound — how   acting,   43 
Rapidity  of  pulse,  see  under  Pulse 
Raynaud's  disease,   described,    117 
Recurrent   pulse,   see  under  Pulse 
Rectum,    injections   by,    of   opium — conve- 
nient mode — advantages  of,   194 
Recumbent  position, 
— best    for    restoring    fainting    persons, 

blood-pressure    in    brain    greater    dur- 
ing,  115 

— impossibility  of  assuming  or  main- 
taining, in  severe  cases  of  valvular 
disease — causes  explained,  132-3 
— inability  to  evacuate  in — author's  ar- 
rangement to  meet  this  difficulty, 
132 

— work  of  diaphragm  in  moving  abdom- 
inal viscera  in,   133 
Recuperation    intervals — how    secured    for 

the  heart  by  digitalis,    149 
Reflex  contraction  of  vessels,  not  present 
in   reflex  stoppage  of   heart   in  imper- 
fect  anaesthesia — author's  view,    113-4 
• — irritation     from     stomach,      paroxysmal 
tachycardia      sometimes      due      to  — 
treatment,    185 
— of  various  organs,   and  skin,  causing 

bradycardia,    109 

—stimulation  of  medullary  center  of 
vagus,  from  stomach,  skin,  or  sexual 
organs — bradycardia  caused  by,  187 
— treatment  for,  aims  and  methods, 
188 

— stoppage  of  heart,  caused  by  stomach 
distension,  140-1 

— in    imperfect    anaesthesia — unaccom- 
panied   by    reflex    contraction    of 
vessels — author's   view,    113-4 
Refractory  period  of  the   heart,  4,   33 
— investigations    on,    as   to    time,    and 
electrical   changes,    of   Sanderson 
and   Page,   33 

pointed  out  by  Marey,  33 — by  Kro- 

necker,  33 

— stimulation  (electric)  non-effective 
during  (Brunton  and  Cash),  34, 
(.fig-)  35 

Regimen,  see  Diet  and  Regimen 
Regulating  function  of  arteries,  4 
Regurgitation   (see  Aortic  and  Mitral   Re- 
gurgitation),  prevention  of,  by  valves 
of  heart,  40 — beneficial  action  in  aid, 
of  digitalis,   150 

Remak's  ganglion — frog's  heart,   19 
Renal  arteries — effect  of  digitalis  on,  sim- 
ilar  to    that    of   ligature   of,    156,    162 
— how  overcome,    163 

— vessels  (see  also  Kidneys) — spasm  of, 
occurring  (with  arrest  of  urinary 
secretion)  in  second  stage  of  action 
of  digitalis — danger  of,  to  man,  160 
Resistance  in  finger  exercises  in  treat- 
ment of  venous  stasis — graduation 
of,  202 

— increased,     to     ventricular     action — dis- 
eases   causing  —  bradycardia    induced 
by,   109 
Respiration,    arterial    pulsation    coincident 

with,  46-7 
— as    coadjutor    to    heart    in    carrying   on 

circulation,   5 
— imperfect,     waste     products     due     to — 

elimination   of,  203 
— movements  of,  effects  of, 
on  circulation   (venous),   5 


Respiration,  movements  of,  effects  of,  on 
flow  of  pleural  and  peritoneal  fluids,  9 

Respiratory  center,  as  affected  by  poison- 
ous doses  of  digitalis,  149 

Rest,    absolute,    in    treatment   of   valvular 
disease    of    the    heart,     13: — author's 
definition  of,   and  insistence  on,   132 
— discomforts  experienced   during,   how 
caused,      132-4 — relieved     by     mas- 
sage,     134 — combined      effects     on 
heart,   etc.,    137 

position    during,    difficulty    connected 

with,   133 

rules  regarding,   132-3 

— after  baths  in  Nauheim  treatment,  200 

— after  meals,  essential  to  those  suffer- 
ing from,  or  menaced  by,  angina  pec- 
toris — why,  192 

— in  bed — prolonged,  the  best  treatment 
for  Graves's  disease — case  illustrat- 
ing, 183-4 

prolonged,    in   severe   cases   of   palpi- 
tation,  183 

— complete,  in  advanced  mitral  disease, 
197 

preferably    in    bed    with    massage,    in 

venous  stasis,   202 

Rest  and  massage,  combined  effects  of, 
in  treatment  of  valvular  disease,  138 
et  pravi. 

Restlessness  in  Graves's  disease — treat- 
ment, 184 

— in  patients  in  absolute  rest  treatment — 
causes,  134 — relieved  by  massage,  135 

Resume  of  the  action   of   digitalis,    147-8 

Retardation  of  pulse-wave,   92,    (fig.)   91 

Rheumatism,  acute,  bradycardia  often 
met  with  when  heart  is  weak,  during 
convalescence  from,  186 

Rhubarb  as  aperient,  in  cases  of  senile 
rise  of  pressure — how  taken,  208 

— with  carminatives,  in  treatment  of  sleep- 
lessness in  cardiac  disease,  193 

Rhythm,  capillary,  47 

— cardiac,   see  Cardiac  Rhythm 

— and  coordination  of  auricles  and  ven- 
tricles, characteristics  of  the  muscle 
itself,  18-9 

Rhythmical  contraction  in  vessels  ob- 
served by  Wharton  Jones  and  others, 
46- — cause  according  to  Luchsinger 
and  Schiff — rediscovered  by  Brunton 
and  Fayrer,  18,  44,  127,  128,  note 
— order,  coincidence  and  number  of, 
46-7 

Richardson,  Dr.  B.  W.,  observations  of, 
on  dilation  of  capillaries  by  nitrite 
of  amyl,  163 

Right  side,  lying  on,  why  resorted  to  by 
sufferers  from  palpitation,  179-80 

Rigidity  (loss  of  elasticity)  of  arterial 
walls  of  old  people,  89,  99,  101,  116, 
205 

Ringer's  discovery  as  to  why  tap-water  is 
better  than  distilled,  in  artificial  cir- 
culation, 143 

Riva-Rocci's  sphygmomanometer,  77-9 — 
modifications  of,  78-81 

Romanes,  Prof.,  experiments  of,  on  me- 
dusae (in  comparison  with  the  heart), 
26-8 

Rooms,  warm,  why  causing  faintness  and 
syncope,  107 

Root  of  tooth,  inflammation  at,  why  re- 
lieved by  cold,  174-5 

Rotator  muscles  of  leg  as  accessories  to 
circulation,  6,  7,  131 


260 


THERAPEUTICS    OF    THE    CIRCULATION 


Roy,  manometer  of,  59 

Roy    and    Adami,    cited    on    regurgitation 

from  irregular  action  of  musculi  pa- 

pillares,   126 
Rupture    of    blood-vessels,     risks    of,     in 

cases  of  arterio-capillary   fibrosis  due 

to  kidney  disease,   101 

• in    cases    of    atheromatous    arteries 

and   high   blood-pressure,   205 

SACRIFICES,  animals  slain  for,  arteries  of, 
empty — reason,  2,  5 

St.  Bartholomew's  Hospital,  purgatives 
employed  at,  in  cardiac  complaints, 
203 

Saline  purgatives  in  treatment  of  angina 
pectoris — when  given — aim  of,  192 

• in  treatment  of  senile  rise  of  pres- 
sure, 208 

• in  treatment  of  toxin-caused  brady- 

cardia,  188 

Saline  solutions,  as  used  in  Ludwig's  ex- 
periments in  artificial  circulation, 
143,  (fig.)  142 

Ringer's  discovery  concerning,   143 

Salt,  common,  solution  of,  used  in  artifi- 
cial circulation,  by  Ludwig,  143 

use  of,  in  Graves's  disease,   184,  note 

Sanderson,  Sir  John  Burdon-,  cardio- 
graph of,  for  apex-beat,  (fig.)  86 

— manometer  made  by,   n,   (fig.)    12 

— investigations  of,  with  Mr.  Page,  on 
refractory  period  of  the  heart,  .13 

Sassy-bark,  or  casca  (Erythrophlceum 
guinense),  medicinal  uses  of,  146, 
1 60 

Scanty  urine,  feature  of  venous  engorge- 
ment, 129 

Schema  of  the  circulation,  author's,  57, 
59,  (fig-)  55 

Schiff,  observations  by,  on  rhythmical 
contraction  of  vessels,  46,  128 

Schmey,  see  Kronecker  and  Schmey 

Schott,  the  brothers,  and  the  Nauheim 
treatment,  199  et  seq. 

Schweigger-Seidel,  see  Brunton  and 
Schweigger-Seidel 

S cilia  maritima   (squill),   uses  of,   146 

Scrotum,  oedema  of,  tapping  for — meth- 
ods, 204 

Second  intercostal  space,  second  sound  of 
heart  best  heard  at,  42 

Sedative  effect  of  smoking,  causes  (prob- 
able) of,  169-70 

Sedatives,  cardiac,  local  and  external,  178 

Self-massage  of, 

— arteries,  lymphatics  and  veins,  6,  9,  97, 
99,  102 

increased  by  digitalis,   149 

— — —by  massage,  137;  and  exercises, 
202 

in  relation  to  the  pulse-wave  and  to 

arterial  nutrition,  102 

— heart,  process  and  advantage  of,  96 

aided  by  digitalis,    149-50 

increased  by  massage  and  exercises, 

202 

by  massage   and  rest,    137 

probably  produced  by  inhalation  of 

oxygen,  203 

Semeiology  of  the  circulation,  2 

Senac,  acquainted  with  the  independent 
pulsation  of  veins  (1783),  18 

Senile  conditions  (see  also  Age,  Elderly 
persons,  Old  Age)  of  arteries,  etc., 
89,  (fig-)  88,  99,  100-1,  116,  205,  207, 
208 — treatment,  208-9 


Senile  conditions  of  the  vessels — treat- 
ment of,  208-9 

Senile  decay,   207 
— causes  of,   actual  and  primary,   207 

Metchnikoff's  views  on,  206-7 

— preventable    by    attention    to    arterial 
conditions,  209 

— gangrene,  causes  of,  and  main  prelimi- 
nary symptom  (Brodie),  116 

— pulse,  analogy  of,  to  ventricular  beat, 
(fig.)  88 

— rise  of  pressure,  205;  conditions  of, 
attended  with  special  risk,  205 

Sensitiveness  of  arteries,  119;  how  proven, 
i i 9-20 

— of  heart,    120-2 

Sensory  affections,  resulting  from  rupture 
of  blood-vessel  in  brain,  205 

— mechanism  in  the  heart,  partly  cause  of 
cardiac  pulsations  —  how  deduced, 
171-2 

Serous  cavity  of  pleura,  effusion  into — 
tapping  for,  204 

Sexual  organs,  reflex  irritation  from,  bra- 
dycardia  due  to,  109,  184 

Sharpey,  Professor,  on  Czermak's  expe- 
rience with  mechanical  irritation  of 
the  vagus,  121,  note 

— on   functions  of  rotators  of  leg,   7-8 

Sheep,  blood-pressure  in,  60 

Shock,  difference  between,  and  syncope, 
114 

— effect  of,  on  heart  and  vessels,   113 

Short-lived  families,  one  reason  for,  205 
— suggestions  for  prolongation  of 
life,  208 

Shortness  of  breath,  in  mitral  incompe- 
tence— treatment,  197 

in    mitral    obstruction    and    regurgita- 
tion— a  prominent  symptom,    128 

Shoulders,  radiation  towards,  of  anginal 
pain,  189 

Sick  headache,  see  Migraine 

Sighing,  caused  by  grief,    104 

Sight,  bad  effect  on,  of  over-smoking,  170 

Sitting  position,  when  advisable  for  suf- 
ferers from  severe  valvular  disease — 
precautions,  133 

Skin,  changes  of  color  in,  due  to  cold 
weather,  what  is  indicated  by,  117 

- — reflex  irritation  from,  bradycardia  due 
to,  109,  187 

— of  toads,  phrynin  from — action  of,  on 
heart,  146-7 

Sleep  of  the  heart,  3,  4,  9 

— positions  in,  in  relation  to  palpitation 
and  nightmare,  179-80 

Sleeplessness,  in  connection  with  cardiac 
disease — characteristics — aggravations 
of — methods  of  relieving,  193  et  seq. 

— effects  in,  of  external  cold,   175 

— - — of  internal   warmth,   ib. 

— in   Graves's  disease — treatment,    i83-4_ 

Slow  eating,  necessary  in  cases  of  palpi- 
tation, 1 8 1,  182 

Slow  walking  after  meals — essential  in 
angina  patients  and  those  menaced 
by  angina,  192 

Slowing  of  the  heart  by, 
aconite — cause — effects,    171 

— — nicotine — cause — effects,    167 

—of  rapid  pulse,  general  bleeding  for,  166 

Slowness  of  pulse,  extreme,  see  Brady- 
cardia 

Skwness  and  strength  of  pulsation  in 
isolated  frog's  heart,  under  digitalis, 
U7 


INDEX 


26l 


Smoke-rings,  watching  of,  sedative  effect 
of,  170 

Smoking,  see  Tobacco-smoking 

Snuff-taking,   nicotine   absorption   in,    168 

Sodium  bicarbonate,  uses  of,  in  certain 
forms  of  tachycardia,  185 

in  palpitation   from   flatulence,    180 

— bromide  of,  in  Graves's  disease — effects 
of,  184 

— hydrate,  in  saline  solution,  as  used  by 
Ludwig  in  experiments  on  isolated 
frog's  heart,  143,  (fig.)  142 

— nitrite,  action  discovered  but  not  an- 
nounced by  author — first  described 
by  Hay,  165-6 

beneficial    in    cases   of    high    tension, 

208 

Solids  and  fluids,  manner  of  taking,  im- 
portant in  diet  for  palpitation,  181-2 

Somerville,  Dr.,  case  of  bradycardia 
treated  by,  referred  to,  188,  note 

Sounds  of  the  heart,  41  et  seq. 

cardiac  murmurs,  43-4 

first — causes  of,  41-2 

— changes    in,    42-3 

causes  of,  ib. 

clinical   importance   of,   ib. 


-nature  of,  41-2 
-where  best  heard,   42 


-second — causes  of,   41 
changes    in,     great    clinical    impor- 
tance of,   42 

— causes  of,  42 

-where  best  heard,  42 


Ja 

La 


Southey's  tubes,    for  drainage  of  legs  or 

scrotum,   204 
Spasmodic    asthma,    permanent    dilatation 

of  right   side   of  heart   induced  by — 

why,   130 
Sphygmograms — character   of,    in    healthy 

people,  90,   (figs.)   88 

in    cases   of   feeble   heart,    90,    (figs.) 

88,  89 

— crochet  or  hook  in,  92,    (fig.)   90 
— dicrotic   wave    in,    what   it   means,    and 

how  caused,  92,   (fig.)   90 
Sphygmograph,    the,    84— principle   of,    86 
— various  forms  of,   devised  by 
-Dudgeon,    93,    (fig.)    94 

Jacquet,    93 

Laulanie,  94,    (fig.)   95 

-Ludwig  and  Von  Frey,  92 
Marey    (several    forms   and    modifica- 
tions of),    13,  86,  92 

— wider    use    of — possibilities    and    condi- 
tions of,   94 
Sphygmomanometers — author's      apparatus 

for  standardizing,  82 
— various  forms  of,  devised  by 

author,  65,   79,    (fig.)   80 

Herisson,  62-64,  68 

Hill,   68 

Hill   &   Barnard,   78 

Martin,   78 

Mosso,  71-3 

Oliver,   67,    (fig.)   67 

Potain,   67,   79,    (figs.)   66 

— fallacies  in   applying,  68 

Riva-Rocci's,   77-9 

modifications  of,   by 

— Americans,   79-82 

— author    (and    method    of    using), 

79 

others,  78-9,   81 

Von   Basch — earlier   designs,   63,   64-5 

— later   designs,   66-7,    (figs.)    64-7 
• author's  cheap   modification   of,   63 


Sphygmomanometers,     various    forms     of, 

fallacies   in    using,    68-9 
— Waller's,  62 

Sphygmoscope,  or  Erlanger's  sphygmo- 
manometer,  81 

Splanchnic  area — influence  of,   16 
— in  regulation  of  blood-pressure,    16 

in  relation  to  vascular  dilatation  and 

faintness,    107 

Splenic  plexus,  see  Coeliac,  Hepatic  and 
Splenic  Plexus 

Squill  (S cilia  maritima),  medicinal  uses 
of,  146 

— digitalis  and  blue  pill — pill  of,  in  car- 
diac diseases,  204 

— useful  in  cardiac  asthma,   193 

Stages  in  the  action  of  digitalis,   158,   159, 

1 60,   (figs.)    156,    157,    159 
— essential  part  of  division  of,   159 
— four  stages  enumerated,    159 

— conditions    rendering    second    stage 

dangerous  to  man,   160 
— not    correspondent   in    different   au- 
thors,   159 

Stairs,  work   involved   in   going  up,    131-2 

Standardization  of  instruments  for  meas- 
uring blood-pressure,  author's  appa- 
ratus for,  82,  (fig.)  83 

Stannius,  experiments  of,  on  movements 
of  frog's  heart,  21,  (figs.)  20,  and 
see  1 6 1,  and  note 

Stanton's  modification  of  Riva-Rocci's 
sphygmomanometer,  80 

Start,  waking  with,  characteristic  of  sleep- 
lessness with  cardiac  disease,  193 

Stenosis,  see  also  Aortic  and  Mitral 
Stenosis 

—to  be  distinguished  from  mere  obstruc- 
tion— why,  122 

• — pure,  slight  degrees  of,  barely  affecting 
circulation,  122 

Sternum,  lower  end  of,  to  the  left — 
aortic  regurgitant  murmur  sometimes 
only  audible  at — case  illustrating, 
195-6 

Stiffness  of  aortic  valves  in  later  life — 
consequences,  122 

Stimulants  (see  also  Cardiac  Stimulants), 
powerful  (e.  g.,  strong  coffee)  in 
attacks  of  paroxysmal  tachycardia, 
benefit  of,  184 

Stimulation,  see  also  Irritation  and  Re- 
flex Irritation 

— electrical,  of  frog's  heart,  experiments 
of  Brunton  and  Cash,  33,  (figs.)  35 
— deductions,  34-5 

— of  feeble  heart,  various  methods  of,  178 

— of  inhibitory  apparatus  in  the  heart,  by 
nicotine — effects  on  arterioles,  168 

— of  secreting  structures  in  kidneys,  by 
digitalis  (probable"*  151-2 

- — of  vagus  center,  in  medulla, 
— by  aconite,    171 
— by   nicotine,    167 
— causing  bradycardia,   109,   188 

— of  vessels  from  within,  49-51,  from 
without,  47,  (figs.)  47,  48 

Stimulus(i),    conduction  of,   by 
— muscle,    23-4;    nerve,   ib. 

— constant,   effect  of, 

on   bell   of   medusa — nerves   removed, 

nerves  detached  at  one  end  only — 
waves  induced  by  irritation — how 
hindered,  27-8,  (figs.)  28 

on  embryonic  heart,  25 


262 


THERAPEUTICS    OF    THE    CIRCULATION 


Stimulus,  generation  in,  and  transmission 
from,  venous  sinus  and  auricles,  un- 
der heat,  1 1  id 

— in  the  heart,  transmission  of,  31-3,  and 
note,  32 

— in  the  pulmonary  veins — possible  mode 
of  excitation  of,  128,  note 

• — to  ventricle,  from  internal  pressure, 
causing  dilatation  of  apex  — •  frog's 
heart — results,  27-8,  128 

Stokes- Adams'  syndrome — characteristics, 
1 86 

Stomach  (see  also  Abdomen),  as  affected 
by  disgust,  104 

— congestion  of — diminished  by  rest  and 
massage,  138 

— discomfort  without  pain,  frequently  felt 
by,  120-1 

- — distension    of,     anginal    pain     increased 

by,   189 

— danger  in,  from  corsets,   141 
— flatulent,  effect  on   heart,    138,    139-41 
— an  aggravation  of  drowsy  sleepless- 
ness of  cardiac   disease — how   re- 
lieved,   193 
— prescriptions  to  alleviate,    180-1 

• — effect  on,  of  (a)  pressure  from  with- 
out, 120 

(b)    distension    from   within,    ib. 

— of  toxic   doses  of  digitalis — parallels, 

155 

• — expulsion  of  gas  from,  by  massage  dur- 
ing rest — advantages  of,  138 

• — fermentation  in — arrest  of,  essential  to 
permanent  relief  of  palpitation,  180 

how   caused — how   prevented,    182-3 

- — flatulence  in  (see  also  under  Stomach 
Distension,  supra),  in  venous  en- 
gorgement, 129 

- — irritants  inside — effect  of,  similar  to 
that  of  blow  on,  113 

- — reflex    irritation     from,    causing    brady- 
cardia,    109,    184 — treatment,    188 
— sometimes     causing     tachycardia  — 
treatment,   185 

— stimulating  effect  on,  of  food,  how  in- 
creased by  aperients,  208 

Stomach  and  intestines,  benefit  to,  of 
reduction  in  size  of  liver,  effected  by 
diminished  venous  congestion,  due  to 
digitalis,  154 

Stooping  position,  helpful  in  averting 
fainting — why,  115 

Stoppage 

— of  heart,   by 

drinking    large    quantities    of    alcohol 

at  a  draught,   113 

— — imperfect    anaesthesia — author's    view, 
H3-4 

shock,    113 

— of  pulse  —  Valsalva's  experiment  —  au- 
thor's tests  on  himself,  130 

Strain,  see  also   Cardiac   Strain 

- — avoidance  of,  by  persons  with  slight 
mitral  leakage,  197 

— from  being  chased,  sensation  from,  the 
same  as  that  felt  in  nightmare — de- 
duction, 1 80 

— constant,  less  well  withstood  than  in- 
termittent, by  involuntary  muscular 
fiber — proof  seen  in  mitral  obstruc- 
tion, 128 

— in  relation  to  stimulation  of  vessels 
from  within,  49-5 1 

—sudden,  and  sudden  death,  relation  be- 
tween, in  aortic  regurgitation,  196 


Strengthening  the  heart,  the  aim  of  all 
treatment  for  bradycardia — most  use- 
ful remedies  for  this,  188 

Strieker  and  others,  contractility  of  cap- 
illaries established  by,  46 

Strontium,  bromide  of,  in  Graves's  dis- 
ease, effects  of,  184 

Stroplianthus  hispidus — medicinal  uses  of, 
146 

action   of,  chiefly  on  heart  itself,    160 

added  to  "  pulvis  mirabilis  "   for   fee- 
ble heart,   181 

— as  cardiac   tonic — nutritive   action   of, 
98 

poisoning  by,   effects  of,   as  observed 

by    Brunton   and   Pye,    155-6 

small    doses    of,    between    attacks    of 

paroxysmal  tachycardia,   benefit  of, 
185 
— useful,   in  aggravated  cases  of  mitral 

incompetence,    197 
— in  cardiac  asthma,    193 

why    good    effects    of,    and    of    other 

drugs,   persist  after   discontinuance 
of,  98-9 

Strychnine, 

— action  of,   complex,  affecting  whole  ner- 
vous  system,    183 
— on  the   heart,   described,    160 
— in  cardiac  asthma,    193 

as    cardiac    tonic — nutrient    action, 

98 
— in   palpitation   with   debility,    183 

• — effect  of,  on  medusae  (contractile  tis- 
sue), 30 

Strychnine    and    caffeine,    in    combination 
with    digitalis,    benefits   of,    in   certain 
.  cases    of    aortic    regurgitation,    with 
care,   196-7 

Strychnine  with  iron,  in  treatment  of 
bradycardia,  188 

Submaxillary  gland,  condition  seen  in,  on 
dilation  of  its  arterioles  from  irrita- 
tion of  chorda  tympani,  115 

— — dilatation   in,    how   induced,   46 

Substances  having  poisonous  action  ab- 
sorbed by  liver,  excreted  in  bile,  re- 
absorbed  from  duodenum,  and  again 
excreted — risks  from,  in  angina  pec- 
toris — how  eliminated,  191 

Suction-power  of  the  heart — how  increased 
by  digitalis,  150 

Sudden  anaemia  of  the  brain,  the  (appar- 
ent) cause  of  syncope,  1 14,  and  see 
15 

— strain  and  sudden  death — relation  be- 
tween, in  aortic  regurgitation,  196 

Sugar (s),  to  be  avoided  in  palpitation — 
why,  181 

• — instead  of  salt  in  foods  for  mitral  dis- 
ease cases,  204 

- — other  than  glucose,  less  good  as  car- 
diac nutrients,  145 

Sulphate  of  zinc  (20  grains),  emetic  to 
cut  short  attack  of  paroxysmal  tachy- 
cardia, 184-5 

Sulphonal,  in  treatment  of  sleeolessness 
in  cardiac  disease — dose,  193 

Sunstroke,    bradycardia   occurring   in,    188 

Suprarenal  extract,  enormous  rise  of 
blood-pressure  due  to — a  parallel,  167 

given  by   author  in   Graves's  disease, 

184 

Surgical  treatment  of  cardiac  diseases, 
205 

of     mitral     stenosis — possibilities     of, 

205,   and  note 


INDEX 


263 


Syncope, 

— association   of,   with   bradycardia,    186 
— causes  of,    15,    (fig.)    14,    107 
— apparent  probable,    114 

heat  of  room,    107 

— strain    on    ossified    coronary    arteries 

(Brodie),  116 

— difference   of,    from  shock,    114 
- — fatal,   from  excessive  use  of  digitalis — 

cases  in  which  most  frequent,    162-3 
— flow    of  blood   during — Hunter's   obser- 
vation on,   115 
— operations   formerly   performed   in   state 

of — method  of,   115 
— pathology  of,  not  thoroughly  made  out, 

114 

— risk   of,   in   aortic   regurgitation,    196 
Syndrome,    Stokes-Adams — characteristics, 

1 86 

Systole,   denned,  3 
— in   dog's  heart,   prolonged   by  irritation 

of  vagus,   158 
— in    frog's   heart — electric   stimulation   of 

ventricle    during — effects   at    different 

stages,   34,    (fig.)    35 
— reduplication  of,  due  to  stimulation,  34, 

(fig-)  35 
Systolic   murmur   over   aorta,    significance 

of,  195. 

indicative    of    mitral    regurgitation — 

when    found  —  interesting    case    of, 
126 

loud,    not    necessarily    indicating    les- 
sened  lumen  of  vessel,    122 
Systolic   and   diastolic  blood-pressure, 

• how  estimated,   -71-2,    (fig.)    70 

highest — relations  between,   82 

TABLETS  of  nitroglycerine  in  angina  pec- 
toris — best  nibbled — safe  dose — sole 
ill-effect,  191 

Tachycardia,   due  to  strain,   184 
• — paroxysmal,    characteristics,    causes   and 

associated  conditions,    108-12,    184-5 
treatment     during     and     between     at- 
tacks,   184-5 

— pulse  in — rate  altered,  rhythm  regu- 
lar— varieties  of  intermission  in, 
109-12 

Tait,  see  Brunton  and  Tait 
"  Taking   it   to    heart,"    pathological   eluci- 
dation  of,    104 

Tambour,    Marey's,    for    recording    move- 
ments,  64,    (figs.)    58,   84,   93 
Tapping,    when   advisable — methods  of,  204 
Tap-water,    why    different    in    effect    from 
distilled  water  in  artificial  circulation 
— Ringer's  discovery,    143 
Tartar  emetic,   effect   of,   on   stomach,    155 
Tea,  to  be  avoided  in  angina  pectpris,  191 
— dietetic    action    of,     162 — -medicinal    ac- 
tion  of  derivatives,    162 
— excessive  use  of,  cause  of  palpitation — 

to   be  cut  off  or  lessened,   179 
• — use  of,   by   flatulent — precautions,    182 
Tea   and   bread,    fatal    meal    of — why    so, 

140-1 
Temporal   artery,    alterations  in,   observed 

during  migraine,    119-20 
Tensor  vaginae  femoris  muscle,  true  func- 

.  tion  of,   7-8 

Thebesius,  vessels  of,  function  of,  96 
Theobromine,    or   dimethylxanthine 
— action    of,    differing    from    that    of    caf- 

eine,    162 

— use  of,   in   small   quantities,    145 
Theocine,  nature  and  uses  of,    162 


Theophyllin,  nature  and  uses  of,   162 

Thtvttta  grandiflora,  action  of — not  used 
in  medicine,  146 

Thighs,  swollen,  effect  of,  on  abdomen, 
133 

Thinking,  hard,  effect  produced  by,  on 
volume  of  arm,  114 

Thirst,  intolerable,  induced  in  healthy 
man  by  diuretic  action  of  digitalis, 
150,  152 

Throat,  irritability  of,  due  to  over-smok- 
ing, 170 

Thrombosis,  obliteration  of  blood-vessels 
due  to,  causing  gangrene,  115-6 

Thyroid  gland  extract,  effect  of,  on  heart, 
vessels  and  pulse  in  exophthalmic 
goitre,  107 

— effects  of  too   long  treatment  with 
(by  mouth),  in  myxcedema,   107 

Tigerstedt,  cited  on  blood-pressure  in 
man,  60 

— referred  to,  on  dilating  nerves,  45,  and 
note 

Tissue (s),  see  also  Muscular  Tissues 

— anaemia  of,  in   Raynaud's  disease,    117 

— how  supplied  with  blood,  5 

— hard  or  unyielding,  in  relation  to  self- 
massage  of  arteries  and  general  cir- 
culation, 6 

— in  relation  to  means  for  modifying  local 
circulation  in  inflammation,  174-5 

— hyaline,  deposit  of,  in  coats  of  arterial 
walls,  due  to  kidney  disease,  101 

Toads'  skin,  poison  from  (phrynin),  effect 
of,  on  heart — story  on,  146-7 

Tobacco  chewing  and  snuffinsr  in  relation 
to  nicotine  absorption,  168 

— enemata,  former  uses  of— dangerous, 
:68 

— smoking,  attractions  and  results  of, 
169-70 

bradycardia  caused  by — how,  109,  187 

characteristic    irregularities   in,    in 

double  action  of,  in  adults,   169 

— excessive,  as  cause  of  palpitation,  to 
be  given  up  wholly  or  partly,  170, 
i.79 

— various  methods  of,  and  their  results, 
168-9 

Tongue,  effect  on,  of  small  quantities  of 
aconite,  171 

— irritation  of,   due  to  over-smoking,   170 

Tonic  contraction — drugs  specially  pro- 
ducing, oxidation  of  protoplasm  accel- 
erated by  (Brunton  and  Cash),  148 

Tonics,   see  Cardiac  Tonics 

Tonometer,  Gaertner's,  73-75,  76,  (figs.) 
74,  75,  76 

Tonsillitis,  benefit  in,  from  aconite  in 
small  doses,  172 

- — benefit  in,  from  cold-water  compress- 
how  produced,  175 

Toxic  action  of  digitalis — symptoms,   155 

Toxin  of  diphtheria,  effect  of,  on  cardiac 
muscles  and  on  vagus  and  other 
nerves,  105 

• — in  typhoid  fever,  stimulation  by,  of  in- 
hibitory mechanism,  effect  of,  on 
pulse,  186 

Toxins  causing  bradycardia  —  treatment, 
187 

—of  various  diseases  causing  fatty  degen- 
eration of  the  heart,  or  degeneration 
of  its  muscular  tissue,  too 

Train  and  telegram,  comparison  of,  with 
transmission  of  stimuli  by  cardiac 
muscle  and  nerves,  32 


264 


THERAPEUTICS    OF   THE    CIRCULATION 


Transudation    from    vessels    into    tissues, 

effect   of   chlorides  in  promoting — con- 
sequent   disadvantage    of,    in    dropsy, 

204 
Transmission  of  stimuli  in  the  heart,  31, 

and  note,  32 
Traube,    experiments    of,    on    mammalian 

circulation     (in    relation    to    digitalis 

action),  146 
— and    Von    Bezold,    views    of,    cited    on 

cause   of   rise   of   blood-pressure    due 

to   digitalis,    157 
Treatment    of    cardiac    diseases,    see    also 

Surgical   Treatment 

angina  pectoris,   189,   191-2 

cardiac  asthma,   192-3 

palpitation,    178,   et  seq. 

senile  conditions  of  the  vessels,  207-9 

sleeplessness  in  cardiac  disease,  193-5 

valvular  disease,   131  et  seq. 

— ultimate   impotence    of,    in    some   cases, 

205 

Tremor,  nervous,  due  to  smoking,   170 
Tricuspid    valves,    incompetence    of,    how 

induced — advantage    of    tendency    to, 

44 
Trimethylxanthine     (see    Caffeine)  —  use, 

145 
Trional,   in   treatment  of  sleeplessness   in 

cardiac  disease — dose,    193 
Tuberculosis,    predisposition    to,    produced 

by  grief — case  in   point,    105 
Tubes,    for   drainage    of    legs   or    scrotum, 

204 
Tumor   on  the  brain,   bradycardia  caused 

by,   109,   187 

Tunnicliffe,   Dr.,   see  Brunton   and  Tunni- 
cliffe 
Turpentine    stupe    over    heart,    stimulating 

effect  of,    178 
Typhoid  fever — 
— bradycardia  often   associated  with  weak 

heart  in  convalescence  from,    186 

seen    in,    even    while    temperature    is 

high — probable  cause,    187 
— fatty  degeneration  of  the  heart  in,    105 
— heart-weakness  causing  bradycardia,    due 

to,   1 08 
— prognosis  grave  when  first  heart  sound 

inaudible,  42-3 

ULCERS,    atheromatous    in    senile    arterial 
walls,   how  induced,    101 

— gastric,    bradycardia,    induced    by,    109, 
187 

Umbilicus,    swollen   liver   reaching   below, 
due  to  venous  pressure,   154 

Unconsciousness  (and  falling),  from  over- 
use of  pig-tail  tobacco,    170 

— in  syncope— ^probable  cause,   114 

Upas   (Antiaris  toricaria),   action   of,  not 
used  medicinally,    146 

Upright   position,   blood-pressure   in  brain 
less  during,    115 

work  of  diaphragm  in  moving  abdom- 
inal viscera  in,    133 

Uraemia,    poison    of,    bradycardia    caused 
by,  187 

Ureter,      discomfort     without     pain     fre- 
quently felt  by,   120 

— effect  on,  of  (a)  pressure   from  without, 

1 20 
— (b)    distension    from   within,   ib. 

Urinary  bladder,    discomfort  without  pain 
frequently   felt  by,    120 

— effect  on,  of  (a)  pressure  from  without, 
1 20 


Urinary  bladder,  effect  on,  of  (b)  dis- 
tension from  within,  ib. 

Urine,  albumen  in,  action  on,  of  mer- 
cury, 208 

due  to  reaction  from  toxic  doses  of 

digitalis,  156 

due  to  venous  engorgement,    129 

in  sleeplessness  of  cardiac  disease  not 

centra-indication  of  use  of  opium 
or  morphine,  195 

— scanty,   in   venous  engorgement,    129 

— secretion  of,  as  affected  by  caffeine, 
150,  161-2 

as  affected  by  digitalis,  increase  in, 

150-1;  often  enormous,  152;  second 
stage,  symptoms  and  danger  in, 
160;  toxic  stage,  stoppage  in — o.b- 
servations  on,  of  Brunton  and 
Power,  and  Brunton  and  Pye,  and 
on  subsequent  condition  of  urine, 
155-6 

Uropherin,   nature  and  uses  of,    162 

Urticaria,   causes  and   symptoms  of,    117 

VAGUS(J),     branches     and     ends     in     the 

heart, 

irritation  of,  in  relation  to  bradycar- 
dia,  1 86 

paralysis  of,  from  aconite,   171 

— from  nicotine,    168 

Vagus  center  (roots)  in  medulla,  effects 
on,  of  aconite — results,  171 

of  digitalis,    146 

— ; — of  nicotine,   167-8 

— in    relation   to   the   emotions,    104,    121, 

(/»£•*•)    100,    101,   103 
- — inhibitory    and    vaso-motor    centers    of, 

as  affected  by  digitalis,    149,    155 
— irritation   of,   causing  bradycardia,causes 
of,   109,   1 88 

how    induced — how    affecting    heart's 

rate,  etc.,   15,    (fig.)    13 

of    (dog's    heart),    prolonged    systole 

secured  by,    158 

(mechanical)     of,    or    pressure    on — 

feeling      of     oppression     of     chest 
caused    by — author's    personal    ob- 
servation— Czermak's    personal    ex- 
perience,  121,  and  note 
— neuritis  of,  in  convalescence  from  diph- 
theria— effects   of,   on   the   pulse,    187 
Vagus    nerve,    organs    to    which    it    gives 

branches,   104 
— origin  of  name,   104 
— paralysis    of, 

from  alcoholic  neuritis,   107 

from    atropine    or    belladonna   in    ex- 
cessive  doses,    107 

from  toxin  of  diphtheria,  105,   107 

pulse-rate   in   men   after,    107 

— roots,   normal,    and   severed,    action   on, 

of  increased   blood-pressure,    105 
Valsalva's   experiment — nature  of,    130 
Valves    of    the     heart     (see    also    under 

_  Names),   39-40 

— aid  given  to,  by  muscular  fibers  round 
auriculo-ventricular  orifice,  40,  (figs.) 
39 

• — non-existent  in  pulmonary  veins — con- 
sequence, 127 

• — non-existent  in  venae  cavse — conse- 
quence, 129 

— numerous,   of   lymphatics  and  veins,    6 
— uses  of,  39-40;  action  of,  how  assisted, 

40,    (figs.)   38,  39 

Valvular  action  of  the  heart  —  how 
strengthened  by  digitalis,  150 


INDEX 


265 


Valvular    diseases    of    the    heart,    122    et 

seq. 

— causes  and  symptoms, 
— aortic   obstruction,    122 

aortic  regurgitation,    122 

— cardiac  strain,   126 

— failing    compensation,    123 

— mitral   incompetence,    124 

treatment     of  —  aims — uses — methods 

— hopefulness  of,   131  et  seq. 
— rest,     absolute,     author's    definition 

of,   and   insistence  on,    130 
— position    in — difficulties    concern- 
ing,  134 

rules     regarding11,     132;     arrange- 
ments for  evacuation  when  re- 
cumbency   or    fixed    position    is 
essential,    132,    13^ 
Valvular      incompetency  • —  lessened      and 

often    overcome    by    digitalis,    150 
Vasa-vasorum,    functions    and    importance 

of,  99 

Vascular  dilatation,  caused  by  heat,    106 
— local,  with  effusion  of  lymph,  a  cause 

of  urticaria,  etc.,  118 

Vascular  dilators,  in  relation  to  high 
blood-pressure  of  gouty  kidney  dis- 
ease, 101 

• requisite     in      cases     of     paroxysmal 

tachycardia  with  high  tension,   185 
Vascular    districts   in    the   body,    the    four 

largest,    (fig.)    16 
Vaso-dilators,    141,    163 
— amyl    nitrite,    163-4 
— hydroxylamine,   166 
— ispbutyl   nitrite,    (fig.)    164 
— nitrites,    163-6 
— nitro-erythrol,    166 
— nitroglycerine,   165 
- — nitro-mannitol,   166 
—sodium,   and   other   nitrites,    166 
- — combination  of,  with  digitalis,  etc. — re- 
sult,  163 
Vaso-motor  nerves,   center(s)    of, 

— location    of    chief    and    subsidiary, 

1 6-7,   45 
— in  medulla, 

— effect  on,  of  caffeine,  how  differ- 
ing in  result  from  that  of  dig- 
italis, 162 

— effect  on,   of  digitalis,   149,    155 — 
action  in  reducing  oedema,   152 
— stimulation   of,   by   nicotine,   effects 
of,   on    arterioles,    167 

influence     of,     on     blood-pressure, 

13-15.    (fig.)  .  i.3 

in   relation   to   migraine,    120 

in    relation    to    oedema,    action    on,    of 

digitalis,   in   reducing  the   disease — 
Ranvier's   experiment,    153 
Vaso-motor    system    as    arterial    turncock, 

Ludwig  cited  on,    5 
Vegetal    growths, 

— on   aortic   valves — often   calcareous,    122 
— on    mitral   valves — consequences,    127 
Vegetarian    diet,    suitable    in    angina    pec- 

toris — points  to  heed  in,   191 
Veins,    see    also    under    Names,    and    see 

Capillaries 

— circulation  in,  how  kept  going,  5-6, 
99,  101-2 

function   of  valves  in,   ib. 

intermittent   external    pressure   in,    ib. 

— independent    pulsation    of,  18,  and  notes, 

44 

— measurement  of  pressure  in,  83-4, 
(figs.)  61,  66,  67 


Veins,      rhythmical     contraction     of,     ob- 
servers  of,    and   views   on,    128,    note 
— stretching    of,    effect    of,    on    walls    of, 

Braune  cited,  6 
• — valves  in,  uses  of,   5 
Venae    cayae,     absence    of    valves    in,    as 
affecting  venous   engorgement,    129 

as  affected  by  raising  of  legs,    133 

of   dog,    Ranvier's  experiment  on,   as 

to   dropsy,    153 

- — independent   pulsation   in,    18,   44 
Vense   cavae   and   pulmonary  veins,   rhyth- 
mical  pulsations  of,   observations  on, 
of     Brunton     and     Fayrer,     and     of 
others,    128,  note 

Venous  blood  from  stomach  and  intes- 
tines— passage  of,  through  liver — 
how  facilitated  by  action  of  digitalis, 
154 

— circulation,  how  benefited  by  digitalis, 
150 

how  maintained — subsidiary  agencies, 

5-6,   99,    102 

— congestion,  effect  of,  on  digestive  and 
assimilative  organs — lessened  by  dig- 
italis, 150-2 

effect  of,   on  kidneys — diminished   by 

digitalis,   151-2 

— engorgement,  cause — first  indication — 
how  relieved — -sequence  of,  and  con- 
sequences, 129 

- — obstruction     in     relation     to,     but     not 
always     concomitant     with,     oedema — 
Ranvier's   experiment,    153 
Venous    sinus     and    auricles,    action    of, 
under  heat,   106 

in    frog's   heart,    19 

— as  affected  by  stimulation,  35,  (fig.) 

36 

Venous  stasis, 
Treatment  of, 

complete   rest   with   massage,    202 

— gentle  exercises,  202 

— inhalation   of   oxygen,   202 

— with    drugs,    in    mitral    incompetence, 

197 

Ventricle  (s),  action  of,  in  mitral  incom- 
petence, 127 

dilatation  of,   from  regurgitation  with 

stenosis,    122 

— in  treatment  of  angina  attacks — 
methods  for,  very  beneficial,  189, 
191 

hypertrophy  of,  in  aortic  regurgita- 
tion— cause — compensatory  effects, 
122 

investigation  of,  with  Marey's  cardio- 
graph— results,  86-7,  (/>£•)  87 

walls   of,    action   of,    in    high    arterial 

tension     and     when  •  hypertrophied, 
as  affecting  first  heart  sound,   43 
- — left,    relative   work  and   strength  of,   44 

yielding    of,    before    strain    of    aortic 

regurgitation — consequences,     196 
— right,    hypertrophy    of,    how    caused    by 
mitral  obstruction — consequent  regur- 
gitation,  129 

relative  work   and   strength  of,   44 

weakness    of,    absolute    or    relative — 

symptoms    produced    by,    similar    to 
those  of  venous  engorgement,    129 
Ventricle(s),  frog's  heart,   19 

frog's  heart,  construction  of,  27-8 

— irritation  (electrical)  of,  results  at 
different  periods  (Brunton  and 
Cash),  34,  (figs.)  35 


266 


THERAPEUTICS    OF    THE    CIRCULATION 


Ventricular  action,  increased  resistance 
to — diseases  causing — bradycardia  in- 
duced by,  1 08 

— beats — frog's  heart — inhibited  by  redu- 
plicated auricular  beat,  due  to  stim- 
ulation, 34,  (fig.)  35 

— cycle,  pressure-changes  during,  ascer- 
tained by  Marey's  cardiograph,  84-7, 
(.fig.)  87 

— pulse,  analogy  of,  to  senile  pulse,  89, 
(fig.)  88 

— systole,  suction  action  of,  Briicke's 
view,  97,  (fig.)  96 

tracing  of,  with  Marey's  cardiograph, 

(fig.)  87 

Vessels,   see   Blood-vessels 
Vocal   cords — false,   in  relation   to  cough- 
ing,   130,   and  note 
Vomiting   center,    as   affected    bv    digitalis 

in  poisonous  doses,    149,    155 
— as  affected  by  disgust,   104 
Vulpian,    observations    by,    on    rhythmical 
contraction  of  vessels,  46 

WALKING-POWERS,  limited,  of  old  persons 
with  degenerated  arterial  walls 
(Brodie),  116 

— slowly  after  meals,  essential  to  angina 
patients  and  those  menaced  by  an- 
gina— why,  192 

— steady,  no  risk  from,  in  aortic  regurgi- 
tation,  196 

— uphill,   in   Oertel's  treatment,   201,   202 

Waller,  Prof.,  observations  of,  on  stimu- 
lation of  the  vagus  center  prevent- 
ing heart's  beating,  16 

— simple  s^  lygmomanometer  of,   62 

Warm-blooded  animals  (see  also  Mam- 
mals), effect  on,  of  heat  and  cold,  51 

— food,  beneficial  in  sleeplessness — why, 
175 

- — poultice  of  heart,  stimulating  effect  of, 
178 

Wassilieff,  fatty  degeneration  of  the 
heart  of  rabbit  found  by,  on  section 
of  the  vagi,  105 


Waste    products,    accumulation    of,    in    ab- 
solute   rest    treatment — cause,     134 — 
relieved  by  massage,    135,    137,    138 
— accumulation   of,   dangers   from,    143 
— in     isolated     frotr's     heart — how     re- 
moved—Ludwig's   experiment,    143, 
(fig.)  142 

elimination    of,    in    cardiac    disease — 

purgatives  for,  203 
— stimulation   by,   of  vessels,    49 

— tissues,  "  ashes "  of,  sec  Waste  Prod- 
ucts. 

Water,  best  way  and  time  for  taking,  by 
the  flatulent,  182 

— withdrawal  of,  from  body,  use  in,  of 
compound  jalap  powder — dose,  203 
— how  effect  may  be  enhanced,  203 

Weakness  of  cardiac  muscle,  indicated  by 
lessened  first  heart  sound,  42-3 

— of  the  heart,  see  Cardiac  Weakness 

— of  right  ventricle — symptoms  of  venous 
engorgement  produced  by^causes  and 
classes  of,  130 

— of  vision,   due  to  smoking,    170 

Weariness,  weight  and  discomfort  felt  in 
limbs  of  persons  in  absolute  rest 
treatment — causes — relieved  by  mas- 
sage, 134  et  seq. 

Weir-Mitchell  treatment  in  severe  cases 
of  palpitation,  183 

Williams,  C.  J.  B.,  apparatus  of,  for  in- 
vestigating action  of  drugs  on  frog's 
heart,  (fig.  and  note)  23 

— and  others,  cause  of  second  sound  of 
heart  ascertained  by,  41 

— discovery  by,  as  to  intensification  of 
first  sound,  42 

Work,    see   Exertion 

Worry,   effect  of,    on   the   circulation,    104 

XANTHINE,  and  other  purin  bodies — use 
of,  145 

ZINC,  sulphate  of,  20-gr.  emetics — to  cut 
short  attack  of  parqxysmal  tachy- 
cardia, 184-5 


INDEX  TO   APPENDIX 


ALCOHOL,  effect  of,  on  the  sensitive  plant 
— author's  experiments,  211 

Algina's  experiments  on  ventricle-beat  in 
frog's  heart,  227 

Amoeba,  undifferentiated  functioning  in, 
212 

Amphibian  hearts — self-massage  in  process 
of — Kronecker  on,  226 

Angina  pectoris,  exercise  in,  why  bene- 
ficial, 223-4 

Animal  protoplasm — higher  and  lower — 
functions  of,  212  et  seq. 

Animals,   effect  on,   of  chloroform,    211 

Arteries,  current  of  blood  in — impor- 
tance of  (rhythmic)  pulse  for,  Kro- 
necker and  Hamel's  experiments 
proving,  231-2 

Asphyxial   blood,   why   poisonous,   226 

Atrio-ventricular  bundle  of  Stanley  Kent 
and  His,  215 

— in  relation  to  coordination  of  heart- 
beats— experiments  of  Kronecker  and 
others,  229 

Auricles  and  ventricles,  normal  contrac- 
tion of,  simultaneous,  229 

Auricles  to  ventricles,  means  of  conduc- 
tion of  stimuli  from,  present  view, 
215 — myogenic  view,  228;  not  en- 
dorsed by  Kronecker's  and  others' 
experiments,  229 

Auricular  and  ventricular  pulsations,  coor- 
dination of,  function  in  regard  to,  of 
Purkinje's  cells,  215 

BALFOUR,  PROF.  J.  H.  (the  late),  and 
other  observers  of  the  functions  of 
vegetable  protoplasm,  211 

Beating  of  the  heart — materials  enabling, 
225-6 

Blastoderm  of  vertebrate  embryo,  layers 
in — corresponding  layers  in  fresh- 
water hydra,  213 

Blood,  asphyxial,  why  poisonous,   226 

— as  cardiac  nutrient,  not  better  than 
serum — why,  226;  when  injurious,  ib. 

— laky  (dissolved  erythrocytes),  why  poi- 
sonous to  the  heart,  226 

Blood-pressure — how  lessened  by  exertion 
of  going  uphill,  224 

— in    man — instruments   for    measuring, 

choice  of,    220 

— Gibson's   clinical   polygraph,   221 
— Janeway's,  216 

— Martin's  new  modification  of  Riva- 
Rocci's,  217,  222;  description, 
directions  for  use,  etc.,  218-9 

choice     of     Mummery's     (Lockhart), 

modification  of   Riva-Rocci's,   220 

Oliver's     new     sphygmomanometer, 

220 

Blood-vessels,  effects  on,  of  muscular 
compression  of,  223,  224 

Boulitte,  M.,  maker  of  sphygmomanome- 
ters,  221,  223 

Bowditch's  law  (on  stimuli  in  relation  to 
resultant  heart-beats),  226;  excep- 


tions, ib. — disproved  by  Kronecker, 
226-7 

Bowditch's  "  Treppe  "  (ascending  stair- 
case), Kronecker's  explanation,  226 

Briicke,  experiments  of,  on  the  functions 
of  vegetable  protoplasm,  211 

— observations  on  the  suction-action  of 
cardiac  systole,  225 

Brunton,  Lauder,  experiments  by,  on 
contractility  and  conduction*  of  stim- 
uli by  vegetable  protoplasm,  211 — 
extracts  from  unpublished  essay  on, 

2 1 1-2 

— extract  from  Harveian  oration  by,  on 
exercise  in  angina  pectoris,  why  ben- 
eficial, 223-4 

Bundle,  see  Atrio-ventricular  Bundle 

CARBOHYDRATES  inadequate  to  replace  al- 
bumen as  heart-food,  225 

Cardiac  energy,  how  maintained,  225 — 
lessened — restored,  226 

• — systole,  suction-action  of,  indicated  by 
Briicke,  225 

Chloroform,  effect  of,  on  animals,  211 — 
on  the  sensitive  plant — Marcet's  ob- 
servations, ib. 

Circulation  through  muscles — two  antago- 
nistic factors  in,  223 

— in  splanchnic  system,  Kronecker's  ex- 
periment, 231-2 

Cold,  as  affecting  the  irritability  of  the 
heart,  Kronecker's  experiments,  227 

• — effect  of,  on  pulsations  of  frog's  heart, 
Kronecker's  experiments,  227 

Coldstream,  experiments  of,  on  the  func- 
tions of  vegetable  protoplasm,  211 

Conduction   of  stimuli,  see   Stimuli 

- — of  stimuli  in  the  heart,  230-1 

Contractility   of   fresh-water   hydra,   214 

— in  vegetable  protoplasm — author's  ex- 
periments, 211 

Contraction,  normal,  of  auricles  and  ven- 
tricles— simultaneous,  229 

Coordination  of  heart-beats, 

how  effected,   228 

how   disorganized,    228,   229 

Coronary  arterial  system,  effects  of  nar- 
rowing on  coordination  of  heart- 
beats, Kronecker  on,  229 

Doc's  bladder — slight  striation  in  invol- 
untary muscle  of  (Schwalbe),  214 

— hearts,  fibrillation  in,  only  overcome 
artificially,  Kronecker's  experiment, 
228-9 

Down  Bros.,  makers  of  Von  Basch's 
sphygmomanometer,  222 

Dutrochet,  experiments  of,  on  the  func- 
tions of  vegetable  protoplasm,  211 

ECTODERM   in  fresh-water  hydra,   function 

connected  with — Ranvier  on,  213 
— cells  of,   functions  of,   213 
Embryonic   muscle,   striation   in,   214 


267 


268 


THERAPEUTICS    OF   THE    CIRCULATION 


Embryo  (s)  of  higher  animals,  incomplete 
differentiation  in,  212 

— vertebrate — blastoderm  of- — layers  in, 
corresponding  layers  in  the  body-wall 
of  fresh-water  hydra,  213 

Endoderm  in  fresh-water  hydra — Ranvier 
on,  212 

Erythrocytes,  dissolved,  why  poisonous  to 
the  heart,  how  made  harmless,  226 

Exercise  in  angina  pectoris — why  bene- 
ficial, 223-4 

FIBRILLARY  action  of  the  heart  —  when 
occurring — how  overcome— Kroneck- 
er's  experiments,  228-9 

Frog's  heart,  pulsations  of,  with  varying 
temperatures  and  stimuli,  Kroneck- 
er's  experiments  and  deductions,  227 

GANGLIA  in  lizards'  hearts,  discovered  by 
Imchanitzky — function  of,  229 

Gibson's  (Dr.  A.  G.),  clinical  polygraph, 
221 

Glycogen  no  adequate  substitute  for  al- 
bumen as  heart-food,  225 

HAMEL,  DR.  G.,  see  Kronecker  and  Hamel 
Harveian      oration,      by      author — extract 
from,  on  exercise  in  angina  pectoris, 
why  beneficial,  223-4 
Heart, 

— conduction   of   stimuli   in,   230-1 
— irritability  of,   as  affected  by  heat  and 

cold,    Kronecker's    experiments,    227 
non-existent  during  systole,  Kroneck- 
er's discovery,   227 

— refractory    period    of,    Kronecker's    dis- 
covery concerning,   227 
— self-massage  of,  Kronecker  on,  225,  226 
— tetanizing  of,   228;   why  impossible,   227 
— work  of,   how  performed,   225 
Heart-beats,    Bowditch's    law    on,    proved 
(without    exceptions)    by    Kronecker, 
226^7 

— coordination  of — the  two  views — -Kro- 
necker's  and  Imchanitzky's  experi- 
ments, 228-9 

Heart-block,    causation    and    treatment    of, 
conduction    of    stimuli    in    regard    to 
problem  of,   225 
Heat    as    affecting   the    irritability    of    the 

heart,    Kronecker's   experiments,    227 
— effect  of,   on  pulsations  of  frog's  heart, 

Kronecker's  experiments.    227 
His,  see  Kent,  Stanley  and  His 
Hydra,   fresh-water,  contractility  of,   214 
— elongatory   power  of — possible   explana- 
tion of,  214 

— incomplete    differentiation    in,    212 
— neuro-muscular  cells   in,    212 — Ranvier's 
description,     212     et     seq. —  observa- 
tions   on,    by    him    and    by    Kleinen- 
berg,  ib. 

IMCHANITZKY,  see  Kronecker  and  Imcha- 
nitzky 

Incoordination  of  heart-beats — how  pro- 
duced— how  readjusted — Kronecker's 
(and  others)  experiments,  228-30 

Inorganic  solutions  incompetent  to  supply 
energy  to  the  heart,  225 

Intermittent  effect  of  constant  stimuli  (.e. 
g.,  chemical),  Kronecker's  experi- 
ments concerning,  227 

Irritability  of  the  heart,  as  affected  by 
heat  and  cold,  Kronecker's  experi- 
ments, 227 


Irritability  of  the  heart,  non-existent  dur- 
ing systole,  Kronecker's  discovery,  227 

JANEWAY'S  sphygmomanometer,  described, 
216 

KENT,  STANLEY  and  His,  Atrio-ventricu- 
lar  bundle  of,  215;  in  relation  to 
coordination  of  heart-beats  • —  experi- 
ments on,  of  Kronecker  and  others, 
229 

Kleinenberg  and  Ranvier's  observations 
on  the  neuro-muscular  cells  in  the 
fresh-water  hydra,  212  et  seq. 

Kronecker,  Professor,  notes  by  (Appen- 
dix D),  225  et  seq. 

Kronecker  and  Algina,  experiments  of, 
on  stimulus  required  to  keep  ventri- 
cles of  frog's  heart  working,  227 

Kronecker  and  Hamel,  experiments  of, 
on  rhythm  of  pulse  and  its  advan- 
tages, 230 

Kronecker  and  Imchanitzky's  experiments 
on  coordination  of  heart-beats,  228-31 

LEUCOCYTES  of  higher  animals — functions 
exercised  by  every  part  of,  212 

Livingstone,  experiments  of,  on  the  func- 
tions of  vegetable  protoplasm,  211 

Lizards'  hearts,  nerves  and  ganglia  in, 
governing  coordination  of  heart-beats, 
discovered  by  Imchanitzky,  229 

Lomakina,  Dr.,  observations  of,  on  dis- 
turbance of  coordination  of  heart- 
beats in  animals'  heart  by  ligature 
not  affecting  the  atrio-ventricular 
bundle,  230 

Ludwig,  Prof.,  experiments  of,  on  effect 
of  muscular  action  on  lymph-flow,  225 

Ludwig,  Prof.,  and  Sadler,  observations 
of,  on  circulation  through  the  mus- 
cles— two  antagonistic  factors  in,  223, 
224 

Lymph-flow,  effect  on,  of  muscular  ac- 
tion, shown  by  Ludwig,  225 

MACAIRE-PRINSEP,  experiments  of,  on  the 
functions  of  vegetable  protoplasm,  211 

Marcet,  experiments  of,  with  chloroform, 
on  the  sensitive  plant,  211 

Martin's  (C.  J.)  new  modification  of  Riva- 
Rocci's  sphygmomanometer,  217 — de- 
scription, directions,  etc.,  218-9 — 
value  and  cheapness  of,  222 

Massage,  internal,  rhythmical  pulse  act- 
ing as,  232 

Mercurial  manometer,  for  testing  accu- 
racy of  Von  Basch's  or  Potain's 
sphygmomanometers,  222 

Mesoderm  in  fresh-water  hydra,  function 
connected  with — Ranvier  on,  213,  214 

Motor  nerve,  stimulation  of — amount  of 
blood  before,  during  and  after,  on 
what  dependent,  223 

Mummery  (Lockhart),  modification  of,  by 
Riva-Rocci's  sphygmomanometer,  220 

Muscle  (s),  circulation  through,  two  an- 
tagonistic factors  in,  223 

— conduction  of  stimuli  by,  modern  view 
on,  225 

— embryonic — striation   in,   214 

— involuntary,  of  dog's  bladder,  slight 
striation  in  (Schwalbe),  214 

— transverse  (hypothetical),  contractility 
of,  214 


INDEX    TO    APPENDIX 


269 


Muscular  action,  effect  of,  on  lymph-flow, 
shown  by  Ludwig,  225 

Myogenic  view  of  coordination  of  heart- 
beats, contrary  deductions  from  Kro- 
necker's  experiments,  228  et  seq. 

NERVE-PLEXUSES,  accompanying  the  bun- 
dle of  Stanley,  Kent  and  His,  dis- 
covery concerning  of  Paukul,  229 

— non-medullated,  effecting  coordination 
of  heart-beats,  effects  of  paralysis  of, 
228 

Nerves,  conduction  of  stimuli  by,  evi- 
denced by  Kronecker's  notes,  225  et 
seq. 

— in  lizards'  hearts — discovered  by  Im- 
chanitzky — function  of,  229 

Nervous  system  in  plants,  author's  prize 
essay  cited  on,  211-2 

Neuro-muscular  cells  in  fresh-water  hy- 
dra, Ranvier's  description,  212  et  seq. 

Notes  by  Professor  Kronecker  (Appen- 
dix D),  225  et  seq. 

(EDEMA,    caused    by    continuous    pressure 

on  vascular  walls,  232 
Oliver's  new  sphygmomanometer,   220 
Oxygen,    not    an    increase    of    work    done 

by  heart,  226 

PAIN  in  heart  enfeebled  by  arterial  dis- 
ease, how  caused,  223-4 

Paralysis  of  non-medullated  nerve-plex- 
uses effecting  coordination  of  heart- 
beats— consequences,  228 — how  over- 
come, Kronecker's  experiments,  229 

Paukul,  Dr.,  discovery  of,  on  Stanley, 
Kent  and  His's  bundle,  in  connec- 
tion with  coordination  of  heart-beats, 
229 

Poisons,  how  acting  on  vegetable  organ- 
isms— gain  derivable  from  discover- 
ing, 212 

Polygraph,  Gibson's  clinical,  221 

Portal  venous  system  of  rabbit — Kro- 
necker's experiment  on,  with  saline 
solution — various  conditions,  232 

Potain's  sphygmomanometer,  ease  with 
which  applied,  222 

Pressure,  continuous,  on  vascular  walls — 
oedema  caused  by,  232 

Protoplasm,   functions  of,   211 

Protoplasm,  animal — higher  and  lower — 
functions  of,  212  et  seq. 

— vegetable,  contractility  and  conduction 
of  stimuli  by,  author's  experiments, 
211 

Pulsations,  auricular  and  ventricular — 
coordination  of — function  in  regard 
to,  of  Purkinje's  cells,  215 

— stimuli,  in  relation  to — Bowditch's  law 
— Kronecker's  proof  of,  226-7 

Pulse — rhythm  in — advantages  of — exper- 
iments of  Kronecker  and  Hamel 
proving,  231-2 

Purkinje's  cells,  functions  of  —  recent 
views,  215,  (.fig.)  214 

RABBIT — portal  venous  system  _  of — Kro- 
necker's experiment  on,  with  saline 
solution — various  nressures,  etc.,  232 

Rabbits'  hearts,  fibrillation  in,  sometimes 
spontaneously  overcome,  228 

Ranvier's  description  of  the  neuro-mus- 
cular  cells  in  the  fresh-water  hydra, 
212  et  seq. 


Refractory  period  of  the  heart,  Kroneck- 
er's discovery,  227 

Rest  of  vascular  walls  secured  by  rhythm 
in  pulse,  advantages  of,  232 

Rhythm  in  pulse,  advantage  of.  experi- 
ments of  Kronecker  and"  Hamel 
proving,  231-2 

Riva-Rocci's  sphygmomanometer, 

Martin's  modification  of,  217,  222 — 

description,  directions,  etc.,  218-9 

Mummery's   modification   of,    220 

SADLER,  see  Ludwig  and  Sadler 

Saline  solutions,  effect  of,  on  cardiac  en- 
ergy, 226 

in    portal    venous    system    of    rabbit, 

flow   of  —  various   conditions — Kro- 
necker's experiment,   232 

Schwalbe,  observation  by,  on  slight  stria- 
tion  in  involuntary  muscle  of  dog's 
bladder,  214 

Self-massage  of  heart,  Kronecker  on,  225, 
226 

Sensitive  plant  (Mimosa  ptidica),  au- 
thor's experiments  on  the  effects  on, 
of  stimuli,  2ii 

Serum  as  a  restorative  of  cardiac  en- 
ergy, 226 

Serumalbumin,  sole  material  enabling  the 
heart  to  beat,  225 

Serumglobulin,  in  relation  to  the  beating 
of  the  heart,  225 

Solutions  of  inorganic  salts — effect  of,  on 
pulsation  of  heart,  225 

Splanchnic  system,  circulation  in,  Kro- 
necker's experiment,  231-2 

Stimuli, 

— conduction  of, 
— from    auricles    to    ventricles,    present 

view,   215 
— in  heart,   230-1 

by    nervous    (as    well    as    muscular) 

channels,    evidenced    by    Kroneck- 
er's notes,  225  et  seq. 
— by  vegetable  "rotoplasm,  author's  ex- 
periments, 211 

— constant  (e.  g.,  chemical)  intermitting 
effect  of,  how  proven,  Kronecker's 
experiments,  227 

— frequent  (intermitting)  reaction  to,  of 
the  heart — one  consequence,  227 

— in  relation  to  pulsations,  Bowditch's 
law,  Kronecker's  proof  of,  226-7 

Stopcock  for  use  with  Von  Basch  s  in- 
strument, 222 

— striation  in  muscle  of  dog's  bladder 
(Schwalbe),  214 

— of  embryo,  214 

— of  Purkinje's  cells,  2ie,    (.fig.)   214 

Suction-action  of  cardiac  systole,  indi- 
cated by  Briicke,  225 

Systole  in  amphibian  hearts,  effect  of,  on 
nutrition,  Kronecker  on,  226 

— in  auricje,  immediate  sequence  of  the 
same  in  ventricle,  229 

—non-irritability  of  the  heart  during, 
Kronecker's  discovery,  227 

- — suction-action  of,  indicated  by  Brucke, 
225 

TETANIZING  of  the  heart,  228 — why  im- 
possible, 227 

VAGUS(I), 

— cardiac — non-effective  on  heart  cavities 
under  local  stimulation,  230 


2/0 


THERAPEUTICS   OF    THE    CIRCULATION 


Vagus,  inhibition  by  (when  stimulated)  .of 
ventricle,  while  not  affecting  auricles 
— Kronecker's  experiment  showing, 
230 

— not  an  anabolic  nerve — how  proved, 
230 

Vascular  walls,  rest  of,  secured  by 
rhythm  of  pulse,  advantage  of,  232 

Vegetable  organisms — effects  on,  of  poi- 
sons, advantage  of  discovering,  212 

— protoplasm — functions  of — author's  ex- 
periments and  (.unpublished)  essay 
on,  2 1 1-2 

Ventricles,  conduction  of  stimuli  to.  from 
auricles,  215  —  Kronecker's  (and 
others')  experiments— deductions  as 
to  coordination  of  heart-beats,  229 

— frog's  heart,  stimulus  required  to  keep 
working,.  Kronecker's  and  Algina's 
experiments,  227 


Ventricles,  inhibition  of,  by  vagi,  while 
auricles  not  affected  —  Kronecker's 
experiment,  230 

— locally  stimulated,  irresponsive  to  in- 
hibitory action  of  vagus,  230 

— no  true  automatism  in — how  deduced, 
227 

Ventricular  septum,  center  in,  for  inner- 
vation  of  coronary  vessels,  Kronecker 
on,  229 

Verdin,  Ch.,  maker  of  sphygmomanom- 
eter,  his  successor,  222 

Von  Basch's  sphygmomanometer,  ease 
with  which  applied,  222 

WALKING  on  the  flat  and  uphill  in  angina 
cases — phenomena  of — how  explica- 
ble, 224 

Work,  the,  of  the  heart,  Kronecker  on, 
225 


CLASSIFIED   LIST  OF   ILLUSTRATIONS 


ACCORDING  TO  SUBJECTS 

NOTE.— The  first  numerals  after  the  word   (Fig.)   refer  to  the  number  of  the  illustra- 
tions,  and  the  second   to  the  page. 


ABDOMEN,  in  normal  state,  and  in  ad- 
vanced dropsy — diagrammatic  section 
of,  fig.  179,  152 

Abdominal  contents,  see  position  in  re- 
gard to,  infra 

Amoeba  quickly  changing  its  form,  fig. 
27,  26 

Aorta,  atheroma  of — sound  indication — 
usual  position  of — diagram  to  show, 
fig.  152,  123 

Aortic  regurgitation  (see  also  under 
Pulse),  occurrence  in,  of  syncope — 
diagram  to  illustrate,  fig.  217,  195; 
tendency  in,  to  syncope  —  diagram 
illustrating,  fig.  153,  124 

Atheromatous  cerebral  artery — section  of, 
fig.  128,  98 

Atrio-ventricular  bundle  of  Stanley,  Kent 
and  His,  seen  from  right  ventricle, 
fig.  213,  215 

BLOOD,  amount  of,  flowing  from  veins  of 
biceps  of  dog  during  tetanus,  fig.  239, 
223 

— distribution  of,  in  the  body,  four  great 
areas    for — diagram    showing,   fig.    13, 
1 6 
— rapidity  of  flow  of,   through  vessels  of 

muscles,  fig.    12,   14 

Blood-pressure  in  dog,  normal,  fig.  183, 
156 

as  affected  by  digitalis,  earlier  stage, 

fig.    184,    156;   later  stage,  fig.  185,  157 

as   affected    by    electrical    stimulation 

of  vagus — before  administration  of 
digitalis,    fig.    186,    if;    after   this, 
fig.   187,   158 
— effect  on,  of  amyl  nitrite,  fig.   190,    164 

of    digitalis,    fig.    188,    159,    and    see 

figs.    183-7,    156-8 

of   hydroxylamine   hydrochlorate,    fig. 

191,   165 

of  isobutyl  nitrite,  fig.  189,   164 

of  massage,  fig.   165,  136 

— equal — nervous  apparatus  to  which  due 

• — diagram  showing,  fig.    1 i,    13 
Blood-pressure    measuring    instruments, 

Brunton's   apparatus   for    ascertaining 

correctness  or  amount  of  error  in 
an  aneroid  sphygmomanometer,  fig. 
103,  83 

arrangement     for     using     a    broad 

Riva-Rocci  band  with  Von 
Basch's  or  Potain's  sphygmoma- 
nometer, instead  of  a  mercurial 
manometer,  fig.  101,  80 

method  of  combining  Ludwig's  and 

Pick's  kymographs  for  register- 
ing blood-pressure  and  pulse,  fig. 
76,  59 

27 


Blood-pressure     measuring    instruments — 

continued 
— Brunton's  modified   Riva-Rocci  band, 

fie.  100,  79 

— Burdon-Sanderson's    cardiograph     for 
apex-beat,  fig.   107,  86 

cardiac   sounds,   by  which  tracings  in 

fig.   108  were  obtained,  fig.   105,  85 
—Dudgeon's  sphygmograph,   fig.  123,  94 
— for   estimating   blood-pressure   in   cap- 
illaries,  fig.  80,   62 

— Pick's    apparatus   for    measuring   and 
recording    changes    in    volume    of 
organs,  fig.  89,  68 
— kymograph,  fig.  75,  58 
— Gaertner's  tonometer,   fig.    95,    74 
— portable  form  of  the  same,  fig.  96, 
75 

mode  of  using  the  latter,  fig.  97, 

75  . 

Gibson's   clinical   polygraph,   fig.   238, 

221 

Herison's    sphygmomanometer,  fig.  81, 

62 

for    indicating    mode    of    contraction 

of    heart   or    nature    of   pulse-wave, 
82  et  seq. 
— Janeway's      sphygmomanometer,      fig. 

234,  216 

— Laulanie's    digital    sphygmograph,  fig. 
124,  95 

manometer,  fig.  9,  12 

Ludwig's  kymograph,  fig.    8,    1 1 ;   fig. 

7i,  56 

Marey  s     apparatus     for      measuring 

blood-pressure  in   a  finger,  fig.    92, 
7i 

• —cardiograph,  fig.    106,  86 

— hsemodynamometer,  fig.    70,    55 
— improved    metallic    manometer,    fig. 
1 02,  8 1 

registering   metallic   manometer,  fig. 

72,   57 

• — sphygmograph,   fig.    120,    92;    mode 
of    applying   the    same,    fig.    121, 

93 

transmitting    form    of    the    above, 

fig.    122,  93 

tambour,     tracings     of     oscillations 

made  with,  fig.  74,   58 

for     recording     movements,     fig. 

104,  82 
— transmitting   sphygmograph, /J£.  122, 

93 

Martin's  modification  of  Riva-Rocci's 

sphygmomanometer,  fig.  235,  217 

mercurial  manometer — oscillations  in, 

fig.  73,  58 

Mosso  s  ergograph.   fig.    164,    135 


272 


THERAPEUTICS    OF    THE    CIRCULATION 


Blood-pressure     measuring     instruments — 

continued 
— Mosso's   plethysmograph,    fig.    90,   69; 

combination     of     the     above,     with 

Marey's    metallic     manometer,    fig. 

91,  70 

sphygmomanometer,   fig.   93,   72 

Mummery's     modification     of     Riva- 

Rocci's       sphygmomanometer,       fig. 

236,  220 
— —Oliver's    sphygmomanometer,    fig.    88, 

67 

new    sphygmomanometer,    fig.    237, 

220 

one    in    which    movements    of    spring 

are  magnified  and  read  off  on  dial, 
fig-  79.  6 1 

plethysmograph  of  Hallion  and  Combe, 

fig,   Q4,   73 

Potain's  modification  of  Von  Basch's 

aneroid  sphygmomanometer,  fig. 
85,  66 — mode  of  applying  the  fore- 
going, fig.  86,  66 

Potain's     and     Gaertner's     apparatus 

combined,   fig.  98,   76 

Riva-Rocci's    sphygmomanometer,    fig. 

99.   78 

simple      instrument      for      measuring 

blood-pressure  in  an  artery,  and 
improvement  on  the  same,  fig.  77 
a  and  b,  60 

sphygmomanometer,    simple,    mode   of 

applying  direct,  on  palpating  fin- 
srer  instead  of  pressing  it  on  artery 
and  feeling  artery  nearer  the  hand, 
fig-  78,  6 1 

Von  Basch's  sphygmomanometer,    (a) 

early   form  of,    (b)    author's  cheap 
modification  of,  fig.   82,   63 
— and  stand,  fig.   8-?,  64 
— aneroid    pattern,    fig.    84,    65 — most 

recent  form,   fig.   87,   67 
Blood-pressure    and    secretion    of    urine, 
relation    between,     after    administra- 
tion  of   erythrophlceum  —  diagram   to 
show,  fig.   182,   155 

Blood-vessels   in   frog's   foot,   normal  con- 
dition, fig.   50,  47;  fig.   195,    173 — the 
same,  after  irritation,  fig.  51,  48;  fig. 
196,    173 
Brain,   in   relation  to  senile   decay — 

cell    from    that   of   woman    aged    TOO 

years,    being    devoured    by    macro- 
phags,  fig.  227,  207 

cerebral    cortex,    showing   distribution 

of  functions,   fig.   226,   206 

distribution    of    arteries    in,    fig.    225, 

206 

CARDIAC  dulness — before  and  after  a  bath 

— diagram  of,  fig.   218,   197 
— sounds,    by   which    tracings   in   fig.    108 

were  obtained,  fig.   105,  85 
Carotid,   temporal  and  occipital  arteries — 

diagrams    of — in    normal    state,    fig. 

149,    118 — in  migraine,  fig.    150,    118; 

fig.   151,   119 
Cells   taken    from   a    heart   in   fibrillation, 

fig.  240,  231 
Circulation  of  the  blood — see  also  Lymph 

Brunton's  schema  of,  fig.   69,   55 

diagram  of,  fig.  7,   10 

flow  of  blood  through  vessels  of  mus- 
cles— rapidity    of  —  diagram    show- 
ing, fig.   12,   14 
increased    rapidity    of,    in    carotid    of 


horse   during  mastication,   fig.    192, 
169 
Circulation  of  the  blood,   artificial, 

effect    on    beat    of    frog's    heart    fed 

with  NaCl  solution,  by  addition  of 
a  trace  of  calcium  chloride,  fig. 
172,  144 

— — of  simple  NaCl  solution  in  weak- 
ening pulsations  of  apex  of  frog's 
heart — tracings  showing,  fig.  171, 
144 

maintenance   of,    Ludwig    and    Coats* 

frog-heart  apparatus,  fig.   170,    142 

through   liver— ^effect   of,   at   different 

pressures — diagram    to     show,     fig. 
14,   17 
- — entero-hepatic  —  diagram    to    illustrate, 

fig-  215,   192 
— portal — veins  forming  part  of,  fig.  201, 

179 
Cold,   effect  of,   on  the  arteries,  fig.    135, 

IO3»  fiS-  200,  176 
Cold    and    heat,    effect   of,    on    the   heart, 

figs.   58-67,  52-3 

Conduction  in  heart  —  atrio-ventricular 
bundle  of  Stanley,  Kent  and  His, 
seen  from  the  right  ventricle,  fig. 
233.  215 

Congestion  of  lung — diagram  to  show, 
fig.  198,  176 

effect     on,     of     counter-irritants,     fig. 

199,    176 

DIGITALIS,  action  of, 

on  dog,  first  stages  of — dog's  blood- 
pressure  before  and  after  admin- 
istration of — tracings  of,  figs.  183- 
84,  156;  fig.  185,  157 

on  frog's  heart — diagram  to  show, 

fig.  174,  147. 

on  muscular  rings  of  cardiac  orifices 

— cases  in  which  called  for,  and 
effects  of,  figs.  175-7  (for  legend, 
see  Valves,  figs.  46-48),  151 

Digitalis-poisoning,  pulse-tracings  from 
case  of,  figs.  140-44,  in 

Dropsy,  Ranvier's  experiment  on — dia- 
gram of,  fig.  180,  153 


EXOPHTHALMIC   goitre- 
185 


case   of,   fig.    202, 


FEVER,  effect  of,  on  pulse,  fig.   137,   106 
Fibrillation,   cells  taken   from  a   heart  in, 

fig.  240,  231 
Flatulence,    effect   of,    on   heart,    fig.    169, 

140 
Frog,  foot  of — vessels  in 

(a)     normal    condition,    fig.     50,    47; 

fig-   195,   173 

(fc)    after   irritation,   fig.    51,   48;   fig. 

196,   173 

— gastrocnemius  of — contraction  in,  enor- 
mous, due  to  solution  of  caffeine,  fig. 
173,  144 

normal   contraction   of,  fig.    54,   50 

— heart  of,   action  on, 

of     digitalis — diagram    to     show,     fig. 

174,   147 

of   drugs — Williams'   apparatus   for 

investigating,  fig.   22,  23 
of     heat,     cold,     and     poisons — au- 
thor's    instrument     for     showing, 
fig.  20,  21 

apex,   effect  of  simple  NaCl   solution 

on  pulsations  of,  fig.   171,    144 


CLASSIFIED    LIST    OF    ILLUSTRATIONS 


273 


Frog,    heart   of,    action   on — continued 
of   the   same,    with   trace   of   cal- 
cium chloride,   fig.    172,    144 
auricle,   effects   on,   of   electrical   stim- 
ulation of  auricle  itself  and  of  ven- 
tricle,  fig.   41,   36 
— auricular    septum    in,    view    of    (seen 

from  left  side),  fig,  24,  24 
— auriculo-ventricular    groove    in — effect 
of     compression     of — Gaskell's     ex- 
periment —  diagram     to     illustrate, 
fig-  37,  32 

diagram  of,  fig.    15,  20 

— difference   in    mode   of   experimenting 
with,     and    with    apex    alone,     dia- 
gram to  show,  fig.  31,   28 
— ligatured         in         auriculo-ventricular 

groove — diagram  of,  fig.   iSf,  20 
— at    junction    of    venous    sinus    with 
auricles — diagram     of,     fig.      170, 
20 

— at    junction    of    venous    sinus    with 
auricles,    and    at   auriculo-ventric- 
ular    groove  —  diagram    of,     fig. 
17 c,  20 
— round  middle   of   auricles — diagram 

of,   fig.    i8<?,   20 
— round    venous    sinus — diagram    of, 

fig.    i8d,   20 

movements    of — -investigation     of — in- 
struments for 
— Bowditch's,  fig.  21,  22 
— Brunton's,    for   showing   effects   on, 
of    heat,    cold,    and    noisons,    fig. 
20,   21 

— Kronecker's  perfusion  cannula, 
with  anterior  part  removed  so 
as  to  show  the  septum,  fig.  23, 
23 

Ludwig     and     Coats'     apparatus, 

fig.   170,   142 

Williams'  apparatus  for  investi- 
gating action  of  drugs  on,  figs. 
22,  23 

— periodic  rhythm  of — pulsations  occur- 
ring in  groups,  separated  by  inter- 
vals .of  complete  quiescence,  fig. 
43.  36 

in   which   sections  have  been  made  at 

junction  of  venous  sinus  with  auri- 
cles,    and      at     auriculo-ventricular 
groove — diagram  of,    iyb,   20 
— successive    contraction    of    cavities    in 
— diagram  to  show,   fig.    16,    19 

ventricle    of,    with    Bidder's    ganglia, 

fig.  30,  27 

effect  on,   of  electrical  stimulation, 

fig-   38,  35 

of    electrical    stimulation    applied 

during    diastole     (reduplication 
of  beat),  fig.  40,  35 

of  electrical   stimulation  after  re- 
fractory period  has  passed  (re- 
duplication,   etc.),    fig.   39,    35 
— increasing     contractions     of,      with 
successive   stimuli,   fig.   33,   28 

—pulsations  of,  when   separated  from 

auricles  by  section  at  auriculo- 
ventricular  groove  —  tracing  of, 
fig.  44,  37 

spiral   ganglion   cell   from  pneumogas- 

tric  of,  fig.  26,   25 

venous  sinus — effects  on,  of  electrical 

stimulation,   fig.   42,   36 

— lungs  of,  effect  of  heat  and  cold  on — 
author's  apparatus  for  ascertaining, 
fig-  68,  54 

19 


HEAT  and  cold,  as  affecting  pain  of  in- 
flammation— diagram  to  show,  fig. 
197,  174 

Heart  of  healthy  man — before  exertion, 
fig-  157.  125;  after  exertion,  fig.  158, 
125 

— in  fibrillation,  cells  taken  from  a,  fig. 
240,  231 

Hydra,  fresh-water — neuro-muscular  cells 
from,  fig.  229,  212 

INFLAMMATION,  effect  on,  pain  of,  of  heat 
and  cold,  fig.  197,  174 

KIDNEY,  effect  on,  of  venous  congestion 
and  of  obstruction  of  ureter  or 
tubules  on  the  kidney — diagram  to 
show,  fig.  178,  152 

LIVER,  artificial  circulation  through,  of 
blood — effect  of,  under  different  pres- 
sures— diagram  to  show,  fig.  14,  17 
— return  through,  of  venous  blood  from 
stomach  and  intestines — diagram  to 
show,  fig.  181,  154 

Lung,  see  Congestion  and  Frogs'  Lungs 
Lymph  circulation,  muscular  action  in  aid 
of — longitudinal  sections  of  muscles 
(i)  in  relaxation,  (2)  in  contraction 
• — effects  of,  on  lymph  circulation — 
diagram  of,  fig.  3,  8 

transverse  section  of  voluntary  mus- 
cle, to  show  pumping  action  ex- 
erted on  muscle-juice  and  waste 
products,  during  action — diagram 
of,  fig.  2,  7 

Lymph  spaces,  injected,  from  fascia  lata 
of  dog,  fig.  4,  8 

MACROPHAGS,  at  work,  figs.  227-8,   207 

Massage,     effect     of,     on     blood-pressure, 
first  causing  slight   rise,   then   distinct 
fall — tracing   to    show,    fig.    165,    136 
— on    flow    of    blood    through    muscle — 

diagram  to   show,   fig.    163,    133 
— in     relief     from     fatigue — tracing     to 
show,  fig.    166,   135 

— mechanical  exerciser,  for  use  in  combi- 
nation with  Mosso's  ergograph,  fig. 
166,  137 

Massage  and  graduated  movements,  effect 
of — pulse-tracing  showing,  fig.  132, 
102;  fig.  167,  138;  fig.  219,  198 

Medusae,  action  on,  of  poisons — method 
of  localizing,  diagrammatic  represen- 
tation of,  fig.  35,  30 

— (Aurelia  aurita)  from  which  ganglia 
have  been  removed,  and  bell  cut  into 
long  strip  with  cross  cuts,  to  block 
passage  of  contractile  and  tentacular 
waves,  fig.  36,  31 

— contractions  in  tissue  of,  increasing 
when  stimulated  by  repeated  weak 
shocks  of  same  intensity,  fig,  32,  28 

— (Sarsia),  natural  size,  fig.  28,  27,  the 
same  inverted,  fig.  29,  27 

—  (Tiaropsis),  about  one-third  natural 
size,  with  strip  of  contractile  tissue 
cut  from  bell,  but  left  attached  at 
one  end — diagram  of,  fig.  34,  28 

Mental  activity,  effect  of,  on  volume  of 
blood  in  arm — diagram  to  show,  fig. 
146,  114 

Migraine,  arteries  concerned  in — dia- 
grams of,  in  normal  state,  fig.  149, 
118 


274 


THERAPEUTICS    OF    THE    CIRCULATION 


Migraine,  arteries  concerned  in — dilata- 
tion and  contraction  of,  during  at- 
tacks, fig.  150,  118;  fig.  151,  119 

Muscles,  longitudinal  section  of,  in  re- 
laxation and  in  contraction— diagram 
of,  fig.  3,  8 

— vessels  of — rapidity  of  flow  of  blood 
through,  fig.  12,  14 

Muscular   contraction, 

as  affected  by  fatigue,  fig.  56,  50 

by  heat  and  cold,      '.   55,  50 

apparatus  for  registering,  fig.   52,   50 

of  gastrocnetnius  of  frog,  (a)  normal, 

fig-  54.  5°.  (W  enormous,  of  the 
same — due  to  caffeine,  fig.  173,  144 

of  a  muscle  with  stimuli  of  .increas- 
ing strength,  fi".  57,  50 

pumping  action  exerted  on  muscle- 
juice  and  waste  products  during 
— diagram  of  transverse  section  of 
voluntary  muscle  to  show,  fig.  2,  7 

revolving  cylinder  for  recording 

movements,  fig.  53,  49 

transverse  (hypothetical)  —  diagram 

to  illustrate,  fig.  49,  46 

NERVOUS  apparatus,  by  which  action  of 
heart  and  vessels  is  coordinated  so 
as  to  maintain  an  equal  blood-pres- 
sure— diagram  to  show,  fig.  11,  13 

hypothetical,  in  the  heart — author's 

diagram  of,  fig.  19,  20 

— mechanism  by  which  action  of  heart 
may  be  depressed  by  irritation  of 
stomach — diagram  to  show,  fig.  168, 
139;  fig-  203,  187 

Neuro-muscular  cells  from  the  fresh-water 
hydra,  fig.  229,  212 

PLEURAL  and  pericardial  cavities — pres- 
sure of  walls  of,  against  each  other 
in  expiration  and  cardiac  diastole — 
diagram  of  transverse  section  of 
thorax  showing,  fig.  127,  97 

tendency  to  formation  of  vacuum 

in,  during  inspiration  and  car- 
diac systole — diagram  of  trans- 
verse section  of  thorax  showing, 
fig.  126,  97 

Pleural  and  oeritoneal  fluids — in  pleura 
and  diaphragm — effect  on,  of  move- 
ments of  respiration 

— section  of  central  tendon  of  diaphragm 
in  rabbit,  fig.  5,  9 

— section  of  pleura,  fig.  6,  9 

Pneumogastric  of  frog — spiral  ganglion 
cell  from,  fig.  26,  25 

Position  of  body,  as  affecting  volume  of 
blood-pressure  in  the  brain,  fig.  147, 
114 

application  of  this  to  prevent  faint- 
ing, fig.  148,  115 

— as  affecting  work  of  diaphragm  on 
abdominal  contents,  figs.  160  and 
161,  133 

Posterior  cardiac  nerve,  part  of,  highly 
majjnified,  showing  ganglia,  fig.  25,  24 

Primitive  bundle  from  a  mammalian  em- 
bryo (about  third  month),  examined 
in  strongly  iodized  serum,  fig.  230, 
213 

Pulsations  of  fontanelle  in  infant  of  six 
weeks  old,  while  sucking,  fig.  198, 
176 

Pulse,  see  also  under  Valvular  Disease, 


Pulse,  in  angina  pectoris— tracings  of, 
figs.  204-14,  190 

— aortic — slow,  due  to  feebleness  in  alter- 
nate beats  of  left  ventricle — tracing 
from  it  and  from  aorta,  fig.  138,  109 

tracings  of,  fig.  108,  87 — cardiac 

sounds  with  which  obtained,  fig. 
105,  85 

— aortic  and  ventricular  systole,  fig.  108, 
87 

— aortic  regurgitation — case  of — showing 
hook  at  top  of  tracing,  fig.  115,  90 

• — dichrotism — tracing    showing,    fig.     116, 

— effect    on,    by    (Nauheim)    baths,    figs. 

221-4,   J99 
— of  digitalis  poisoning,  figs.   140-4,  in 

of  exercises,  fig.  220,   198 

of  fever,  fig.  113,  89 

of   increased    tension  —  sphygmogram 

showing,  fig.    no,   89 

of  intermittent  fever — various  stages, 

fig.   114,  89 

of  massage  and   graduated  movements, 

fig.    132,    102;   fig.    167,    138;   fig.   219, 
198 

— healthy — three  tracings  of,  with  var- 
ious degrees  of  tension — highest  due 
to  cold — lessened  due  to  warm  cloth- 
ing, fig.  112,  88 

— irregularity  of,  caused  by  digitalis  poi- 
soning, figs,  ido-4,  in 

— normal — tracing  of,  fig.    in,   88 

— radial,  before  and  after  haemorrhage, 
same  patient,  figs.  117  and  n8_,  91 

— retardation  of,  in  different  arteries,  fig. 
119,  91 

— senile — analogy  of,  to  ventricular  beat 
— diagram  to  show,  fig.  109,  88 

— slow,  in  aorta,  due  to  each  alternate 
beat  of  ventricle  being  too  weak  to 
overcome  pressure  within  aorta  and 
lift  the  aortic  valves — tracing  from 
left  ventricle  and  aorta,  showing, 
fig.  138,  109 

Purkinje's  fibers,  from  a  sheep  s  heart, 
fig.  232,  214 

RENAL  tubule  invaded  with  microphags 
— old  man  aged  90 — fig.  228,  207 

Rabbit's  ear — vaso-motor  nerves  of — dia- 
•gram  of,  fig.  194,  172 

SELF-MASSAGE  of  artery (ies), 

arterial     pulse — effect    of,     in     aiding 

onward  flow  of  venous  blood  and 
lymph  by  a  process  of  what  may 
be  called  self-massage,  fig.  i,  6; 
fig.  129,  99 

— of  artery  and  nerve  in  sheath  of  con- 
nective tissue — diagram  of,  to  illus- 
trate, fig.  162,  134 

Self-massage  of  the  heart,  Brucke's  view 
of  suction-action  of  ventricular  sys- 
tole in  drawing  blood  from  the  veins 
into  the  auricle — -diagram  to  illus- 
trate, fig.  125,  96 

— thorax,  transverse  section  of,  during 
expiration  and  cardiac  diastole — dia- 
gram of,  showing  pressure  of  walls 
of  pleural  and  pericardial  cavities 
against  one  another,  fig.  127,  97 

inspiration     and     cardiac     systole — 

diagram  of,  showing  tendency 
to  formation  of  a  vacuum  in 
pleural  and  pericardial  cavities, 
fig.  126,  97 


CLASSIFIED    LIST    OF    ILLUSTRATIONS 


275 


Shock,  effects  of  on  the  heart  and  its 
action,  Goltz's  experiments — diagram 
to  illustrate,  fig.  145,  113 

Stannius,  experiments  of,  Brunton's  dia- 
grams illustrating,  figs.  17  and  18,  20 

Stoppage  of  heart  by  stimulation  of 
vagus  (q.  v.),  fig.  130,  100 

Striation,  traces  of,  cells  of  involuntary 
muscle  from  bladder  of  dog  show- 
ing, fig-  231,  214 

Syncope,  causation  of — diagram  to  show, 
fig.  10,  12 

— occurrence  of,  in  aortic  regurgitation 
— diagram  to  illustrate,  fig.  217,  195 

— tendency  to,  in  aortic  regurgitation, 
fig.  153,  124 

VAGUS  nerve, 

afferent    channels    through    which    it 

may     be     stimulateu  —  diagram    to 
show,  fig.   139,   no 

stimulation  of 

diminished  amplitude  of  contrac- 
tion without  slowing  or  stoppage, 
during,  fig.  133,  103 

diminished    amplitude    and    slowing 

of    pulsations    without    complete 
stoppage,   during,  fig.    131,    101 

increased   cardiac   action   from,   fig. 

134,   103  , 

stoppage    of    heart    from,    fig.    130, 

100 

Valves  of  the  heart, 
— mitral   and   tricuspid 
• competence  of  author's  simple  instru- 
ment   for    ascertaining,    and    illus- 
trating action  of  musculi  papillares 
— diagram  of,  fig.  45,  38 

heart   in    full    systole,    showing   these 

orifices  so  diminished  by  muscular 
contraction  that  they  close  easily, 
fig-  46,  39,  and  fig.  176,  151;  same 
heart  from  another  point  of  view, 
fig-  47,  39,  and  fig.  177,  151 
• heart  fully  distended,  showing  in- 


sufficiency of,  to  close  these  ori- 
fices, fig.  48,  39  (the  same  fig.), 
fig-  175,  151 

Valves,  sigmoid — work  of,  in  defence  of 
auricle  and  ventricle  in  diastole — 
diagram  of  healthy  heart  showing,  fig. 
154,  124 

Valvular  disease  of  the  heart — 

— aortic  regurgitation — tendency  in,  to 
syncope — diagram  to  illustrate,  fig. 
153,  "4 

— atheroma  of  aorta — usual  position  of 
murmur  indicating — diagram  to  show, 
fig.  152,  123 

— healthy   heart  in   diastole,  fig.    154,    124 

— heart  of  healthy  man  before  and  after 
violent  exertion — skiagraphs  of,  figs. 
157  and  158,  125 

with  incompetent  aortic  valves,  fig. 

155,  124 

with  incompetent  aortic  and  mitral 

valves,  fig.  156,  124 

— pulse,  in  case  of  mitral  incompetence — • 
tracing  of,  fig.  159,  128 

Vaso-motor  nerves  of  rabbit's  ear — dia- 
gram of,  fig.  194,  1/2 

Venous  blood,  return  of,  from  stomach 
and  intestines  through  liver  —  dia- 
gram to  show,  fig.  181,  154 

— circulation  and  lymph  circulation — dia- 
gram showing  effect  of  arterial  pulse 
in  aiding,  fig.  i,  6 

Ventricular  systole — suction-action  of,  in 
drawing  blood  from  veins  into  auri- 
cle— Brucke's  view — diagram  to  illus- 
trate, fig.  125,  96 

— tracings  of,  tig.  108,  87 — cardiac  sounds 
with  which  obtained,  fig.  105,  85 

Vomiting  center  —  afferent  nerves  by 
which  it  may  be  excited  to  action, 
fig.  216,  194 

WARM  clothing,  effect  of,  in  dilating  ar- 
terioles,  quickening  pulse,  and  reduc- 
ing high  tension,  fig.  136,  106 


LIST  OF   ILLUSTRATIONS 


IN   NUMERICAL  ORDER 


FIG.  i. — Diagram  to  show  effect  of  ar- 
terial pulse  in  aiding  onward  flow  of 
venous  blood  and  lymph,  by  a  process 
of  what  may  be  called  self-massage,  6 

FIG.  2. — Diagram  of  transverse  section  of 
voluntary  muscle,  to  show  pumping  ac- 
tion exerted  on  muscle-juice  .and  waste 
products  during  action,  7 

FIG.  3. — Diagram  of  longitudinal  sections 
of  muscles — I.  in  relaxation,  and  II.  in 
contraction,  8 

FIG.  4. — Injected  lymph  spaces  from  the 
fascia  lata  of  the  dog,  after  Ludwig 
and  Schweigger-Seidel,  8 

FIG.  5.- — Section  of  central  tendon  of  dia- 
phragm in  rabbit,  after  Ludwig  and 
Schweigger-Seidel,  9 

FIG.  6. — Section  of  pleura,  after  Ludwig 
and  Dybkowsky,  9 

FIG.  7. — Diagram   of   the  circulation,    10 

FIG.  8. — Ludwig' s  kymograph,    1 1 

FIG.  9. — Laulanie's   manometer,    12 

FIG.  10. — Diagram  to  show  causation  of 
syncope,  12 

FIG.  ii. — Diagram  to  show  nervous  appa- 
ratus by  which  action  of  heart  and 
vessels  is  coordinated  so  as  to  maintain 
equal  blood-pressure,  13 

FIG.  12. — Shows  rapidity  with  which  blood 
flows  through  vessels  of  muscles,  after 
Ludwig,  14 

FIG.  13. — Diagram  showing  four  great 
areas  for  distribution  of  blood  in  the 
body,  1 6 

FIG.  14. — Diagram  to  show  effect  of  arti- 
ficial circulation  of  blood  through  liver, 
under  different  pressures,  17 

FIG.  15. — Diagram  of  frog's  heart,  19 

FIG.  16. — Diagram  to  show  successive  con- 
traction of  cavities  in  frog's  heart,  19 

FIG.  17  and  18. — Author's  diagrams  to 
illustrate  experiments  of  Stannius,  20 

FIG.  19. — Author's  diagram  of  hypothet- 
ical nervous  apparatus  in  heart,  20 

FIG.  20. — Author's  instrument  for  show- 
ing action  of  heat,  cold  and  poisons  on 
frog's  heart,  21 

FIG.  21. — Bowditch's  apparatus  for  exper- 
iments on  frog's  heart,  22 

FIG.  22. — Diagram  of  Williams'  apparatus 
for  investigating  action  of  drugs  on 
heart  of  frog,  23 

FIG.  23. — Kronecker's  perfusion  cannula, 
with  anterior  part  removed  so  as  to 
show  septum,  23 

FIG.  24. — View  of  auricular  septum  in 
frog  (seen  from  left  side),  after  Ran- 
vier,  24 

FIG.  25. — Part  of  posterior  cardiac  nerve, 
highly  magnified,  showing  ganglia,  after 
Ranvier,  24 

FIG.  26. — Spinal  ganglion  cell  from  pneu- 
mogastric  of  frog,  after  Ranvier,  25 


FIG.  27. — Amoeba  quickly  changing  its 
form,  26 

FIG.  28. — Medusa  (Sarsia),  natural  size, 
27 

FIG.  29. — Medusa  (Sarsia),  natural  size 
(inverted),  27 

FIG.  30. — Ventricle  of  frog's  heart  with 
Bidder's  ganglia,  27 

FIG.  31. — Diagram  to  show  difference  in 
mode  of  experimenting  with  heart  and 
with  apex  alone,  28 

FIG.  32. — Shows  increasing  contractions  of 
tissue  of  medusa  when  stimulated  by 
repeated  weak  induction  shocks  of  same 
intensity  (Romanes),  28 

FIG.  33. — Increasing  contractions  of  ven- 
tricle of  frog's  heart  with  successive 
stimuli,  after  Bowditch,  28 

FIG.  34. — Diagram  of  a  medusa  (Tiarop- 
sis),  about  one-thkd  natural  size,  with 
strip  of  contractile  tissue  cut  from  bell, 
but  left  attached  at  one  end,  28 

FIG.  35. — Diagrammatic  representation  of 
method  of  localizing  action  of  poisons 
on  medusae,  30 

FIG.  36. — Medusa  (Aurelia  aurita),  from 
which  ganglia  have  been  removed  and 
bell  cut  into  long  strip,  with  cross  cuts 
to  block  passage  of  contractile  and  ten- 
tacular waves,  after  Romanes,  31 

FIG.  37. — Diagram  to  illustrate  Gaskell's 
experiment  (compression  of  auriculo- 
ventricular  groove  in  frog's  heart),  32 

FIG.  38. — Tracing  showing  effect  of  elec- 
trical stimulation  upon  ventricle  of 
frog's  heart,  Brunton  and  Cash,  35 

FIG.  39. — Effect  of  electrical  stimulation 
of  frog's  ventricle  after  refractory 
period  has  passed,  Brunton  and  Cash, 

35 

FIG.  40. — Shows  reduplication  of  beat  of 
ventricle  of  frog's  heart,  from  electrical 
stimulation  applied  to  it  during  dias- 
tole, Brunton  and  Cash,  35 

FIG.  41. — Shows  effect  of  stimulation  of 
auricle  (frog's  heart)  on  beats  of 
auricle  itself  and  of  ventricle,  Brunton 
and  Cash,  36 

FIG.  42. — Shows  effect  of  electrical  stimu- 
lation of  venous  sinus,  Brunton  and 
Cash,  36 

FIG.  43. — Periodic  rhythm  of  frog's  heart, 
the  pulsations  occurring  in  groups  sep- 
arated by  intervals  of  complete  quies- 
cence, Brunton  and  Cash,  36 

FIG.  44. — Tracing  of  pulsations  of  ven- 
tricle separated  from  auricles  by  sec- 
tion at  auriculo-ventricular  groove, 
after  Ranvier,  37 

FIG.  45. — Diagram  of  author's  instrument 
for  ascertaining  competence  of  mitral 
or  tricuspid  valves,  and  illustrating  ac- 
tion of  musculi  papillares,  38 


277 


278 


THERAPEUTICS    OF   THE    CIRCULATION 


FIG.  46: — Heart  in  full  systole,  showing 
mitral  and  tricuspid  orifices  so  dimin- 
ished by  muscular  contraction  that  the 
valves  close  them  easily,  39 

FIG.  47. — Same  heart  as  in  Fig.  46,  from 
another  point  of  view,  39 

FIG.  48. — Heart  fully  distended,  showing 
insufficiency  of  valves  to  close  mitral 
and  tricuspid  orifices,  39 

FIG.  49. — Diagram  to  illustrate  hypothet- 
ical transverse  contraction  of  muscle,  46 

FIG.  50. — Vessels  in  web  of  frog's  foot  in 
normal  condition,  after  Lister,  47 

FIG.  51. — Same  vessels  as  in  Fig.  50,  after 
irritation,  48 

FIG.  52. — Apparatus  for  registering  mus- 
cular contraction,  48 

FIG.  53. — Revolving  cylinder  for  record- 
ing movements,  49 

FIG.  54. — Tracing  of  normal  contraction 
of  gastrocnemius  of  frog,  50 

Fig.  55. — Effect  of  heat  and  cold  on  mus- 
cle, 50 

FIG.   56. — Effect  of  fatigue  on  muscle,   50 

FIG.  57. — Tracing  of  contractions  of  mus- 
cle with  stimuli  of  increasing  strength, 
5° 

FIGS.  58-67. — Effects  of  cold  and  heat  on 
heart,  52-53 

FIG.  68. — Author's  apparatus  for  ascer- 
taining effect  of  heat  and  cold  on  ves- 
sels of  frog's  lungs,  54 

FIG.  69. — Author's  schema  of  the  circula- 
tion, 55 

FIG.    70. — Marey's   haemodynamometer,   55 

FIG.  71. — Ludwig's  kymograph,   56 

FIG.  72. — Registering  metallic  manometer 
of  Marey,  57 

FIG.  73. — Tracing  of  oscillations  in  mer- 
curial manometer,  58 

FIG.  74.  —  Tracing  made  with  one  of 
Marey's  tambours  (oscillations),  58 

FIG.   75. — Fick's  kymograph,   58 

FIG.  76. — Diagram  to  illustrate  author's 
method  of  combining  Ludwig's  and 
Fick's  kymographs  for  registering  blood- 
pressure  and  pulse,  59 

FIG.  77.  —  (a)  Simple  instrument  for 
measuring  blood-pressure  in  artery,  (&) 
improvement  on  this,  60 

FIG.  78. — Shows  mode  of  applying  simple 
sphygmomanometer  by  pressing  it  di- 
rectly on  palpating  finger  instead  of  on 
artery,  and  feeling  artery  nearer  hand, 
61 

FIG.  79. — Shows  instrument  (for  measur- 
ing blood-pressure)  in  which  movements 
of  spring  are  magnified  and  read  off  on 
dial,  6 1 

FIG.  80. — Instrument  for  estimating  pres- 
sure of  blood  in  capillaries,  62 

FIG.  8 1. — Sphygmomanometer  of  Heris- 
son,  after  Marey,  62 

FIG.  82. — (a)  Early  form  of  Von  Basch's 
sphygmomanometer,  (b)  author's  cheap 
modification  of,  63 

FIG.  83. — Von  Basch's  sphygmomanometer 
and  stand,  drawn  from  one  in  author's 
possession,  64 

FIG.  84.  —  Von  Basch's  sphygmomanom- 
eter, aneroid  pattern,  from  specimen  in 
possession  of  author,  65 

FIG.  85. — Potain's  modification  of  Von 
Basch's  aneroid  sphygmomanometer,  66 

FIG.  86. — Mode  of  applying  Potain's  ane- 
roid sphygmomanometer,  66 


FIG.  87. — Most  recent  form  of  Von  Basch's 
aneroid  sphygmomanometer,  67 

FIG.    88. — Oliver's   sphygmomanometer,   67 

FIG.  89. — Picks'  apparatus  for  measuring 
and  recording  changes  in  volume  of 
organs,  after  Marey,  68 

FIG.  90. — Mosso's  plethysmograph,  69 

FIG.  91. — Combination  of  plethysmograph 
with  Marey's  metallic  manometer,  70 

FIG.  92. — Marey's  apparatus  for  measur- 
ing blood-pressure  in  finger,  71 

FIG.    93. — Mosso's    sphygmomanometer,  72 

FIG.  94. — Plethysmograph  of  Hallion  and 
Combe,  73 

FIG.  95. — Gaertner's  tonometer,  74 

FIG.  96. — Gaertner's  tonometer,  portable 
form,  75  , 

FIG.  97. — Mode  of  using  Gaertner's  tono- 
meter, 75 

FIG.  98.- — Combined  Potain's  and  Gaert- 
ner's apparatus  for  estimating  blood- 
pressure,  76 

FIG.  99.  —  Riva-Rocci's  sphygmomano- 
meter, 78 

FIG.  100. — Author's  modified  Riva-Rocci 
band,  79 

FIG.  101. — Author's  arrangement  for  using 
broad  Riva-Rocci  band  with  Von  Basch's 
or  Potain's  sphygmomanometer,  instead 
of  mercurial  manometer,  80 

FIG.  1 02.  —  Marey's  improved  metallic 
manometer,  81 

FIG.  103. — Author's  apparatus  for  ascer- 
taining correctness  or  amount  of  error 
in  aneroid  sphygmomanometer,  83 

FIG.  104. — Marey's  tambour  for  record- 
ing movements,  84 

FIG.  105. — Cardiac  sounds,  by  which  the 
tracings,  Fig.  108,  were  obtained,  85 

FIG.   1 06. — Marey's  cardiograph,  86 

FIG.  107.  —  Burdon-Sanderson's  cardio- 
graph for  apex-beat,  86 

FIG.  1 08. — Tracings  of  ventricular  systole 
(i)  and  of  aortic  pulse  (2),  87 

FIG.  109. — Diagram  to  show  analogy  of 
senile  pulse  to  ventricular  beat,  after 
Marey,  88 

FIG.  1 10. — Sphygmogram  showing  effect 
of  increased  tension  on  pulse,  after 
Marey,  88 

FIG.   in. — Tracing  of  normal  pulse,  88 

FIG.  112. — Shows  three  tracings  of  healthy 
pulse,  with  varying  degrees  of  tension, 
after  Marey,  88 

FIG.  113. — Effect  of  fever  on  pulse,  after 
Marey,  89 

FIG.  1 14. — Tracings  of  pulse  at  different 
stages  of  intermittent  fever,  89 

FIG.  115. — Tracing  from  case  of  aortic 
regurgitation,  showing  hook  at  top  of 
tracing,  90 

FIG.  116. — Tracing  showing  dichrotism,  90 

FIG.  117. — Radial  pulse  before  haemor- 
rhage, after  Marey,  91 

FIG.  118. — Radial  pulse  from  same  pa- 
tient, after  haemorrhage,  after  Lorain, 
91 

FIG.  119. — Retardation  of  pulse  in  differ- 
ent arteries,  after  Marey,  91 

FIG.    120. — Marey's  sphygmograph,   92 

FIG.  121.  —  Mode  of  applying  Marey's 
sphygmograph,  93 

FIG.  122. — Marey's  transmitting  sphygmo- 
graph, 93 

FIG.    123. — Dudgeon  s  sphygmograph,   94 

FIG.  124.  —  Laulanie's  digital  sphygmo- 
graph, 95 


LIST    OF    ILLUSTRATIONS 


2/9 


FIG.  125. — Diagram  to  illustrate  Brucke's 
view  of  suction  action  of  ventricular 
systole  in  drawing  blood  from  veins 
into  auricle,  96 

FIG.  126. — Diagram  of  transverse  section 
of  thorax  during  inspiration  and  car- 
diac systole;  shows  tendency  to  forma- 
tion of  vacuum  in  pleural  and  peri- 
cardial  cavities,  97 

FIG.  127. — Diagram  of  transverse  section 
of  chest  during  expiration  and  cardiac 
diastole,  showing  pressure  of  walls  of 
pleural  and  pericardial  cavities  against 
each  other,  97 

FIG.  128. — Section  of  atheromatous  cere- 
bral artery,  after  Ziegler,  98 

FIG.  129. — (Same  as  Fig.  i.)  Artery  and 
vein  in  common  sheath,  to  show  effect 
of  arterial  pulse  in  aiding  venous  cir- 
culation, 99 

FIG.  130.  —  Tracing  showing  stoppage  of 
heart  by  stimulation  of  vagus  (Gaskell), 
100 

FIG.  131.  —  Tracing  showing  diminished 
amplitude  and  slowing  of  pulsations 
without  complete  stoppage,  during  irri- 
tation of  vagus,  101 

FIG.  132. — Pulse-tracing  showing  effect  of 
massage  and  gradual  movements,  102 

FIG.  133.  —  Tracing  showing  diminished 
amplitude  of  contraction  without  slow- 
ing or  stoppage  during  irritation  of 
vagus,  after  Gaskell,  103 

FIG.  134. — Showing  increased  cardiac  ac- 
tion from  stimulation  of  vagus,  after 
Gaskell,  103 

FIG.  135. — Showing  effect  of  cold  upon 
arteries,  after  Winternitz,  103 

FIG.  136. —  (Same  as  Fig.  112.)  Shows 
effect  of  warm  clothing  in  dilating  ar- 
terioles,  quickening  pulse,  and  reducing 
high  tension  of  I  to  low  tension  of  3, 
after  Marey,  106 

FIG.  137. — (Same  as  Fig.  113.)  Effect  of 
fever  on  pulse,  106 

FIG.  138.  —  Tracings  from  left  ventricle 
and  aorta,  showing  slow  pulse  in  aorta, 
due  to  each  alternate  beat  of  ventricle 
being  too  weak  to  overcome  pressure 
within  aorta  and  lift  aortic  valves,  after 
Marey,  109 

FIG.  139. — Diagram  to  show  afferent  chan-. 
nels  through  which  the  vagus  may  be 
stimulated,  no 

FIGS.  140-4. — Pulse-tracings  from  case  of 
poisoning  by  digitalis,  showing  pulse 
variations,  in 

FIG.  145. — Diagram  to  illustrate  Goltz's 
experiments  (effect  of  shock  on  heart), 

113 
FIG.   146. — To  show  contraction  of  vessels 

in  left  arm  produced  during  process  of 

multiplying  245   by    15,    114 
FIG.     147. — Tracing    from    brain,    upright 

position    and   inclined   forward,    114 
FIG.     148. — Attitude    to    prevent    fainting, 

US 

FIG.  149. — Diagram  of  carotid,  temporal, 
and  occipital  arteries  in  normal  state, 
118 

FIG.  150. — Diagram  of  arteries  during  mi- 
graine, showing  dilatation  of  carotid 
and  spasmodic  contractions  of  temporal 
arteries,  118 

FIG.  151. — -Diagram  of  arteries  during 
migraine,  showing  dilatation  of  carotid 
and  temporal  arteries,  and  spasmodic 


contraction  of  ascending  frontal  branch 
of  anterior  temporal  artery,  119 

FIG.  152. — Diagram  to  show  usual  posi- 
tion of  murmur  which  indicates  ather- 
oma  of  aorta,  123 

FIG.  153. — (Same  as  Fig.  10.)  Diagram 
to  illustrate  tendency  to  syncope  in 
aortic  regurgitation,  124 

FIG.  154. — Diagram  of  healthy  heart  in 
diastole,  124 

FIG.  155. — Diagram  of  heart  with  incom- 
petent aortic  valves,  124 

FIG.  156.- — Diagram  of  heart  with  incom- 
petent aortic  and  mitral  valves,  124 

FIG.  157. — Photograph  by  Rontgen  rays 
(skiagram),  showing  heart  in  healthy 
man  before  exertion,  after  Schott,  125 

FIG.  158.  —  Skiagram  (photographed  by 
Rontgen  rays)  of  heart  of  same  man 
as  Fig.  157,  after  violent  exertion, 
showing  temporary  dilatation,  after 
Schott,  125 

FIG.  159. — -Tracing  of  pulse  from  case  of 
mitral  incompetence,  after  Marey,  128 

FIG.  160. — To  show  lifting  of  abdominal 
contents  during  inspiration  in  supine 
position,  133 

FIG.  161.  —  Diagram  to  show  horizontal 
motion  of  abdominal  contents  in  upright 
position,  133 

FIG.  162.— Diagram  of  artery  and  nerve 
in  sheath  of  connective  tissue,  to  illus- 
trate self-massage  of  artery  and  nerves, 

J34 

FIG.  163. — Diagram  to  show  effect  of 
massage  on  flow  of  blood  through  mus- 
cle, by  Brunton  and  Tunnicliffe,  135 

FIG.    164. — Mosso's  ergograph,    135 

FIG.  165. — Tracing  showing  effect  of  mas- 
sage on  blood-pressure,  first  causing 
slight  rise  and  then  distinct  fall,  by 
Brunton  and  Tunnicliffe,  136 

FIG.  1 66. — To  show  relief  from  fatigue 
produced  by  massage,  after  Maggiora 
and  Vinaj,  137 

FIG.  167. — (Same  as  Fig.  132.)  Pulse- 
tracing  showing  effect  of  massage  and 
graduated  movements,  138 

FIG.  1 68. — Diagram  to  show  nervous  mech- 
anism by  which  action  of  heart  may  be 
depressed  by  irritation  of  stomach,  139 

FIG.  169.  —  Diagram  to  show  effect  of 
flatulence  on  heart,  140 

FIG.  170. — Ludwig  and  Coats'  frog-heart 
apparatus,  142 

FIG.  171. — Tracings  showing  effect  of  sim- 
ple NaCl  solution  in  weakening  pulsa- 
tions of  apex  of  frog's  heart,  after 
Ringer,  144 

FIG.  172.  —  Shows  effect  produced  upon 
beat  of  frog's  heart  fed  with  NaCl  solu- 
tion, by  addition  of  trace  of  calcium 
chloride,  after  Ringer,  144 

FIG.  173.  —  Tracing  showing  enormous 
contraction  of  gastrocnemius  of  frog 
by  solution  of  caffeine,  144 

FIG.  174. — Diagram  to  show  action  of 
digitalis  on  frog's  heart,  147 

FIG.  175. — (Same  as  Fig.  48.)  Heart 
fully  distended,  showing  insufficiency  of 
valves  to  close  mitral  and  tricuspid 
orifices,  151 

FIG.  176. — (Same  as  Fig.  46.)  Heart  in 
full  systole,  showing  mitral  and  tri- 
cuspid orifices  so  diminished  by  muscu- 
lar contraction  that  valves  close  them 
easily,  151 


280 


THERAPEUTICS    OF    THE    CIRCULATION 


FIG.  177.  —  (Same  as  Fig.  47.)  Same 
heart  as  in  Fig.  176,  from  another  point 
of  view,  151 

FIG.  178. — Diagram  to  show  effect  of 
venous  congestion  and  of  obstruction  of 
ureter  or  tubules  on  kidney,  152 

FIG.  179. — Diagrammatic  section  of  ab- 
domen— (a)  normal  state,  (b)  in  ad- 
vanced dropsy,  152 

FIG.  1 80. — Diagram  of  Ranvier's  experi- 
ment on  dropsy,  153 

FIG.  181. — Diagram  to  show  return  of 
venous  blood  from  stomach  and  intes- 
tines through  liver,  154 

FIG.  182. — Diagram  to  show  relation  be- 
tween blood-pressure  and  secretion  of 
urine  after  administration  of  erythro- 
phloeum,  155 

FIG.  183. — Tracings  to  show  first  stages 
of  action  of  digitalis  (Brunton  and 
Meyer),  156 

FIG.  184. — Tracing  from  same  animal 
(dog)  after  administration  of  digitalis, 
156 

FIG.  185.  - —  Tracing  from  same  animal 
when  action  of  digitalis  is  more  pro- 
nounced, 157 

FIG.  1 86. — Tracing  of  blood-pressure  of 
dog  during  arrest  of  heart  by  electrical 
stimulation  of  vagus  before  injection 
of  digitalis,  157 

FIG.  187. — Same  experiment  as  in  Fig. 
186,  but  after  injection  of  digitalis,  158 

FIG.  1 88. — -Tracings  of  blood-pressure 
showing  action  of  digitalis,  159 

FIG.  189. — Tracing  showing  action  of  iso- 
butyl  nitrite  on  blood  pressure,  164 

FIG.  190. — Tracing  showing  action  of  amyl 
nitrite  on  blood-pressure,  164 

FIG.  191. — Action  of  hydroxylamine  hy- 
drochlorate  on  blood-pressure,  165 

FIG.  192. — Tracing  to  show  increased  ra- 
pidity of  circulation  in  carotid  of 
horse  during  mastication  (Marey),  169 

FIG.  193. — Pulsations  of  fontanelle  in  in- 
fant six  weeks  old  while  sucking 
(Salathe),  170 

FIG.  194. — Diagram  of  vaso-motor  nerves 
of  rabbit's  ear,  172 

FIG.  195. — (Same  as  Fig.  50.)  Blood- 
vessels in  normal  condition  (Lister), 

FIG.  196. — (Same  as  Fig.  51.)  Same 
vessels  after  application  of  irritant  and 
commencement  of  inflammation  (Lis- 
ter), 173 

FIG.  197. — Diagram  to  show  effects  of 
heat  and  cold  in  lessening  pain  of  in- 
flammation, 174 

FIG.  198. — Diagram  to  show  congestion  of 
the  lung,  176 

FIG.  199. — Diagram  to  explain  action  of 
counter-irritation,  176  . 

FIG.  200. — Showing  effect  of  cold  upon 
arteries,  176 

FIG.  20 1.  —  Rectum  and  haemorrhoidal 
plexus — diagram  of  veins  forming  part 
of  portal  circulation,  179 


FIG.  202. — Case  of  exophthalmic  goitre, 
185 

FIG.  203. — (Same  as  Fig.  168.)  Diagram 
to  show  nervous  mechanism  by  which 
action  of  heart  may  be  depressed  by 
irritation  of  stomach,  187 

FIGS.  204-14. — Tracings  of  pulse  in  an- 
gina pectoris,  190 

FIG.  215. — Diagram  to  illustrate  entero- 
hepatic  circulation,  192 

FIG.  216.  —  Diagram  showing  afferent 
nerves  by  which  vomiting  center  may 
be  excited  to  action,  194 

FIG.  217. — Diagram  to  illustrate  occur- 
rence of  syncope  in  cases  of  aortic 
regurgitation,  195 

FIG.  218.  —  Diagram  of  cardiac  dulness 
before  and  after  a  bath  (Schott),  197 

FIG.  219. — Pulse-tracing,  showing  effect 
of  massage  and  graduated  movements 
(Hamel),  198 

FIG.  220. — Pulse-tracing  to  show  effect  of 
exercises,  198 

FIGS.  221-4. — Tracings  from  pulse  of  pa- 
tient aged  62,  with  gouty  kidney,  of 
failing  heart,  effect  on,  of  Nauheim 
baths,  199 

FIG.  225. — Distribution  of  arteries  in  brain 
(Ross),  206 

FIG.  226. — Cerebral  cortex  showing  dis- 
tribution of  function  (Osier),  206 

FIG.  227. — Cell  from  brain  of  woman  aged 
100  years,  being  devoured  by  macro- 
phags  (Metchnikoff),  207 

FIG.  228. — Section  of  renal  tubule  in- 
vaded by  macrophags,  from  body  of  old 
man  aged  90  years  (Metchnikoff),  207 

FIG.  229. — Neuro-muscular  cells  from  the 
fresh-water  hydra,  212 

FIG.  230. — Primitive  bundle  from  a  mam- 
malian embryo  (about  third  month), 
examined  in  strongly  iodized  serum, 
213 

FIG.  231. — Cells  of  involuntary  muscle 
from  the  bladder  of  the  dog,  showing 
traces  of  striation,  214 

FIG.  232. — Purkinje's  fibers,  from  a  sheep's 
heart,  214 

FIG.  233.  —  Atrio-ventricular  bundle  of 
Stanley,  Kent  and  His,  seen  from  the 
right  ventricle,  215 

FIG.  234. — Janeway's  sphygmomanometer, 
216 

FIG.  235. — C.  J.  Martin's  modification  of 
Riva-Rocci's  sphygmomanometer,  217 

FIG.  236. — Lockhart  Mummery's  modifica- 
tion of  Riva-Rocci's  sphygmomanometer, 
220 

FIG.  237. — Oliver's  new  sphygmomano- 
meter, 220 

FIG.  238. — Gibson's  clinical  polygraph,  221 

FIG.  239. — Amount  of  blood  flowing  from 
veins  of  biceps  of  dog  during  tetanus, 
223 

FIG.  240. — Cells  taken  from  a  heart  in 
fibrillation,  231 


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